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2005 

Choosing A 
Medigap Policy 

A Guide to Health Insurance 
for People With Medicare 



PUBS 

RA 

412 

.3 

C66 

2005 



This official government guide can help you 

• Learn what a Medigap 

(Medicare Supplement Insurance) policy is. 

• Decide if you want to buy a Medigap policy. 

• Understand when you can buy a 
Medigap policy. 

• Choose the Medigap policy that best 
meets your needs. 

• Understand how Medigap policies will 
change when Medicare prescription drug 
plans start in 2006. 

• Know where to go if you have questions. 



Developed jointly by the Centers for Medicare & Medicaid Services 
(CMS) and the National Association of Insurance Commissioners 








How to use this Guide 

There are two ways to find the information you need: 

1. The "Table of Contents" on pages 1-2 can help you 
find the sections you need to read. 

2. The "List of Topics" on pages 94-97 lists 
every topic in this Guide and the page number to 
find it on. 



Who should read this Guide 

This guide was written to help people with the Original 
Medicare Plan understand Medigap (Medicare 
Supplement Insurance) policies. 

A Medigap policy is private insurance that helps you pay 
for some of the costs that Medicare doesn't pay for. 
This guide explains in detail how Medigap policies work. 
It also includes information about new Medicare 
prescription drug plans (starting in 2006) and how these 
plans will change Medigap policies. 

If you have a Medigap policy with prescription drug 
coverage, you should read pages 39-40. 



The "2005 Choosing A Medigap Policy: A Guide to Health Insurance 
for People With Medicare" isn't a legal document. The official 
Medicare Program provisions are contained in the relevant laws, 
regulations, and rulings. 




M 



Section 1: How Medicare and Medigap 
Policies are Changing 



3-6 



What's NEW in Medicare 4 

What's NEW in Medigap policies 5 



Section 2: Medicare Overview 



7-10 



What is Medicare? 8 

What is Medicare Part A? 8 

What is Medicare Part B? 8 

What are Medicare Health Plans? 9 

Original Medicare Plan and Medigap policies at a glance 9-10 

Medicare Advantage Plans at a glance 10 



Section 3: What You Need to Know About 
Medigap Policies 



11-36 



What it is and isn't 12-14 

Why you might need a Medigap policy 14-15 

Who can buy a Medigap policy 16 

What is Medicare SELECT 16 

What's not covered by Medigap policies 16 

How Medigap Plans A through J differ from Medigap Plans K and L 17 

What Medigap policies cover 18 

Basic Benefits for Medigap Plans A through J 18 

Basic Benefits for Medigap Plans K and L 19 

Overview of Medigap Plans A through J 20 

Overview of Medigap Plans K and L 21 

Information on Medigap costs 22-25 

How much policies cost, ways of pricing policies, 

and what can affect the cost 
Buying a Medigap policy 26-28 

Best time to buy and information on Medigap 

Open Enrollment Period 

Pre-existing conditions 29 

Creditable coverage (past health care coverage) 30-31 

Switching Medigap policies 32 

Losing Medigap coverage 33 

How your bills get paid 34 

Illegal insurance practices 35 

Reliable insurance companies 36 



Continued 
on next 
page •=!> 

1 



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Section 4: Prescription Drug Coverage Overview 37-40 

Medicare prescription drug plans 38 

Medigap policies and Medicare prescription drug plans 39-40 

Section 5: Steps to Buying a Medigap Policy 41-52 

Steps to buying a Medigap policy 42-52 

Section 6: Medigap Rights and Protections 53-64 

Medigap rights and protections (guaranteed issue rights) 54-63 

Section 7: Medigap Policies and Disability or ESRD 65-68 

Information on disability and End-Stage Renal Disease 66-68 

Section 8: Other Ways to Pay Health Care Costs 69-78 

Other kinds of insurance and ways to pay health care costs 70-77 

Section 9: Massachusetts, Minnesota, and 

Wisconsin Medigap Plans 79-82 

Information for Massachusetts 80 

Information for Minnesota 81 

Information for Wisconsin 82 

For information about Medigap policies sold in other states, see pages 19 and 21. 

Section 10: For More Information 83-86 



Where to get information 84 

Where to call with Medicare questions 84 

Important telephone numbers for each state 85-86 

Section 11: Words to Know 87-92 

Where words in green are defined 88-91 

Section 12: List of Topics 93-97 

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An alphabetical list of what is in this Guide 94-97 



section 




How 

Medicare 
and Medigap 
Policies 
are Changing 



Use this section 

to find out about 

the changes 

in 2006. 



Section 1: How Medicare and Medigap Policies are Changing 



If you already have a Medigap policy or you are thinking about 
buying a Medigap policy, there are a few things you should know 
about what's new in Medicare and how Medigap policies are 
changing. Below is a quick look at these changes. 

What's NEW in Medicare 

A new Federal law has brought many new changes to the 
Medicare Program. The following changes give you even more 
choices in how you get your health care benefits, including 
coverage for prescription drugs. 

Medicare prescription drug coverage — Starting in 2006 

• Enrollment in Medicare prescription drug plans starts in 
2005. Medicare prescription drug plans will begin coverage 
on January 1, 2006. 

New Medicare-covered preventive services — Starts in 2005 

• Cardiovascular screening blood tests 

• Diabetes screening tests 

• "Welcome to Medicare" physical exam 

To learn more about Medicare choices or changes, you can get a 
free copy of the "Medicare & You" handbook (CMS Pub. No. 
10050) by visiting www.medicare.gov on the web. Select "Search 
Tools" at the top of the page. This website also includes information 
on what Medicare health plans and Medigap policies are available 
in your area. Or, call 1-800-MEDICARE (1-800-633-4227). 
TTY users should call 1-877-486-2048. 



Section 1: How Medicare and Medigap Policies are Changing 



If you live in 
Massachusetts, 
Minnesota, or 
Wisconsin, see 
pages 80-82. 



Note: Medigap 
Plans H, I, and J 
are different 
from Medicare 
prescription 
drug plans. 



What's NEW in Medigap (Medicare Supplement 
Insurance) policies 

New Medigap policies 

The new Federal law gives you more choices in Medigap policies. 
In addition to Medigap Plans A through J, two new Medigap policies 
will be offered in 2005 (Medigap Plans K and L). Below is a quick 
look at the two new Medigap policies. 

Medigap Plans K and L will offer 

• different benefits than Medigap Plans A through J. 

• lower premiums than Medigap Plans A through J. 

If you use the benefits in Medigap Plans K and L, you will have to 
pay higher out-of-pocket costs than Medigap Plans A through J. 
Otherwise, Medigap Plans A through J may be cheaper. 

To learn about the types of benefits that Medigap Plans K and L 
offer, see pages 19 and 21. 

For more information about how Medigap Plans A through J are 
different from Medigap Plans K and L, see page 17. 

Note: If you bought your Medigap policy before 1992 or live in 
Massachusetts, Minnesota, or Wisconsin, your Medigap policy may 
be called something different. 

Changes to Medigap policies with prescription drug coverage 

Medicare will start to offer prescription drug coverage starting 
January 1, 2006. Some Medigap policies offer prescription drug 
coverage, and the new Medicare prescription drug coverage will 
affect those policies. 

• Beginning January 1 , 2006, when Medicare prescription drug 
plans start, you won't be able to buy a new Medigap policy 
covering prescription drugs. These same policies may still be sold, 
but without prescription drug coverage. 

• If the Medigap policy that you have now covers prescription drugs, 
you will get detailed information in the mail from your Medigap 
insurance company about your drug options (see page 39 and 
Situation #8 on page 62). You will need to decide which drug 
option best meets your needs. Help will be available. 






Section 1: How Medicare and Medigap Policies are Changing 



Words in green 
are defined on 
pages 88-91. 



Where can I get more information about 
what's new in Medicare and Medigap policies? 

If you have questions about Medicare, Medicare prescription 
drug plans, Medigap policies, or other Medicare-related 
questions, you can visit www.medicare.gov on the web. 
Or, call 1-800-MEDICARE (1-800-633-4227). TTY users 
should call 1-877-486-2048. You can also call your State 
Health Insurance Assistance Program (see pages 85-86). 



6 



section 




Medicare 
Overview 



Use this section to 

learn the basics of 

Medicare. 



Section 2: Medicare Overview 




Words in green 
are defined on 
pages 88-91. 



Before you decide whether or not to buy a Medigap policy, there are a 
few things you should know about Medicare and Medicare health plans. 
The next few pages give you a quick look at Medicare and how 
Medicare health plans work with Medigap policies. 

If you already know the basics about Medicare and Medicare health 
plans, turn to Section 3 "What You Need to Know About Medigap 
Policies," which starts on page 1 1 . 

If you want to learn more about the new Medicare prescription drug 
plans and how they affect Medigap policies, read Section 4 "Prescription 
Drug Coverage Overview," which starts on page 37. 

What is Medicare? 

Medicare is a health insurance program for 

• people age 65 or older, 

• people under age 65 with certain disabilities, and 

• people of all ages with End-Stage Renal Disease (permanent 
kidney failure requiring dialysis or a kidney transplant). 

Medicare has 

• Medicare Part A (Hospital Insurance), 

• Medicare Part B (Medical Insurance), and 

• Medicare prescription drug coverage. 

Starting November 15, 2005, you can enroll in a Medicare 
prescription drug plan. Medicare prescription drug plans will 
begin coverage on January 1, 2006. For information about 
Medicare prescription drug plans, see page 37. 

What is Medicare Part A? 

Medicare Part A helps cover your inpatient care in hospitals, including 
critical access hospitals, and skilled nursing facilities (not custodial or 
long-term care) when they are medically necessary. 

What is Medicare Part B? 

Medicare Part B helps cover your doctors' services and outpatient care. 
It also covers some other medical services that Part A doesn't cover. 
These services are covered when they are medically necessary. 



8 



. 



■• 



Section 2: Medicare Overview 



Note: Medigap 
policies aren't 
Medicare 
Advantage Plans. 



What are Medicare Health Plans? 

Medicare health plans provide different ways to get your health care 
coverage in the Medicare Program. Your Medicare health plan choices 
include the following: 

• The Original Medicare Plan — Available nationwide. If you have 
this plan, you may want to buy a Medigap policy. 

• Medicare Advantage Plans — Available in many areas. If you have 
one of these plans, you don't need a Medigap policy. Medicare 
Advantage Plans include 

■ Medicare Managed Care Plans (like HMOs) 

■ Medicare Preferred Provider Organization Plans (PPO) 

■ Medicare Private Fee-for-Service Plans (PFFS) 

■ Medicare Special Needs Plans 

The Medicare health plan that you choose affects many things like cost, 
benefits, doctor choice, convenience, and quality. No matter how you 
choose to get your health care, you are still in the Medicare Program. 

Original Medicare Plan and Medigap policies 
at a glance 

If you get your health care from the Original Medicare Plan, you use 
your red, white, and blue Medicare card (see sample card on page 27) 
which tells you if you have Medicare Part A, Part B, or both. You don't 
need Medicare Part B to be in the Original Medicare Plan. However, 
you generally must have Medicare Part A and Part B to buy a 
Medigap policy. 

The Original Medicare Plan pays for many health care services and 
supplies, but it doesn't pay all of your health care costs. There are costs 
that you must pay, like coinsurance, copayments, and deductibles . 
These costs are called "gaps" in Medicare coverage. 



ecuon 



eaicare uverview 




Note: If you have 
End- Stage Renal 
Disease, you 
usually can't join 
a Medicare 
Advantage Plan. 



Original Medicare Plan and Medigap policies at a glance 
(continued) 

You might want to consider buying a Medigap policy to cover these gaps 
in Medicare coverage. Some Medigap policies also cover benefits that 
Medicare doesn't cover, like Medicare Part B excess charges and 
emergency health care while traveling outside the U.S. A Medigap policy 
may help you save on out-of-pocket costs. If you buy a Medigap policy, 
you will also have to pay a monthly premium to the private insurance 
company that sells you the policy. 

Medigap policies only help pay health care costs if you are in the Original 
Medicare Plan. To learn what Medigap policies cover, see pages 43-48. 

Medicare Advantage Plans at a glance 

If you decide to join a Medicare Advantage Plan, you will still have a 
Medicare card, but you need to use the membership card that you get 
from the plan for your health care. These plans often give you extra 
benefits, like coverage for extra days in the hospital, than the Original 
Medicare Plan. 

If Medicare Advantage Plans are available in your area, and you have 
Medicare Part A and Part B, you can join one and get your 
Medicare-covered benefits through the plan. You will have to pay the 
monthly Medicare Part B premium ($78.20 in 2005). In addition, you 
might have to pay a monthly premium to your Medicare Advantage Plan 
for the extra benefits that they offer. You should call the Medicare 
Advantage Plans for more information. 

If you are in a Medicare Advantage Plan, you don't need a Medigap 
policy, because Medicare Advantage Plans generally cover many of the 
same benefits that a Medigap policy would cover. Medigap policies 
won't work with Medicare Advantage Plans. 

Note: If you have a Medigap policy and you join a Medicare Advantage 
Plan, you must drop your Medigap policy. If you drop your Medigap 
policy, you may not be able to get it back with the same benefits. 



10 



Where can I get more information? 

Get a free copy of the "Medicare & You" handbook (CMS Pub. 
No. 10050) or "Your Medicare Benefits" (CMS Pub. No. 101 16) at 
www.medicare.gov on the web. Select "Search Tools" at the top of the 
page. You can also call 1-800-MEDICARE (1-800-633-4227). TTY 
users should call 1-877-486-2048. 



section ^% 




What You 
Need to 

Know About 

Medigap 

Policies 



This section 

includes information^ 

about what Medigap 

policies are, what they 

cover and don't cover, 

cost information, the 

best time to buy 

and more. 




Section 3: What You Need to Know About Medigap Policies 



What is a Medigap policy? 

A Medigap policy is health insurance sold by private insurance 
companies to fill the "gaps" in Original Medicare Plan coverage. 
Medigap policies help pay some of the health care costs that the 
Original Medicare Plan doesn't cover. If you are in the Original 
Medicare Plan and have a Medigap policy, then Medicare and 
your Medigap policy will each pay its share of covered health 
care costs. 



If you live in 
Massachusetts, 
Minnesota, or 
Wisconsin, 

different types of 
standardized 
Medigap policies 
are sold in your 
state (see pages 
80-82). 



Insurance companies can only sell you a "standardized" Medigap 
policy. These Medigap policies are standardized so you can 
compare them easily. 

Since 1992, there have been 10 standardized Medigap policies 
called Plans "A" through "J." In 2005, there will be two new 
standardized Medigap policies available, called Plans "K" and "L." 
You may be able to choose from up to 12 different standardized 
Medigap policies (Plans A through L). 

Medigap policies must follow Federal and state laws. These laws 
protect you. The front of a Medigap policy must clearly identify it 
as "Medicare Supplement Insurance." Each Plan, A through L, 
has a different set of basic and extra benefits (see pages 18-21). 

It's important to compare Medigap policies, because costs can 
vary. The standardized Medigap policies that insurance companies 
offer must provide the same benefits. Generally, the only 
difference between Medigap policies sold by different insurance 
companies might be the cost. Also, insurance companies that sell 
Medigap policies don't have to offer every Medigap plan 
(A through L). Each insurance company decides which Medigap 
policies they want to sell. 



12 



I 



Section 3: What You Need to Know About Medigap Policies 



What is a Medigap policy? (continued) 

Generally, when you buy a Medigap policy you must have 
Medicare Part A and Part B. You will have to pay the monthly 
Medicare Part B premium ($78.20 in 2005). In addition, you will 
have to pay a premium to the Medigap insurance company. As long 
as you pay your premium, your Medigap policy is guaranteed 
renewable. This means it is automatically renewed each year. 
Your coverage will continue year after year as long as you pay 
your premium. 



Words in green 
are defined on 
pages 88-91. 



You and your spouse must buy separate Medigap policies. 
Your Medigap policy won't cover any health care costs for 
your spouse. 

Important: In some states, insurance companies may refuse to 
renew a Medigap policy bought before 1990. At the time these 
Medigap policies were sold, state law might not have required that 
Medigap policies be guaranteed renewable. 

It is illegal for anyone to sell you a Medigap policy if 

• you are in a Medicare Advantage Plan (like an HMO, PPO, 
or PFFS). 

• you have Medicaid. There are certain exceptions (see page 75). 

• you already have a Medigap policy (unless you are cancelling 
your old Medigap policy). 



13 




mm«iTOiwiiMiiWiF 




What are some examples of coverage that are 
NOT a Medigap policy? 

A Medigap policy is different from 

• a Medicare Advantage Plan, 

• Medicare Part B, 

• a Medicare prescription drug plan, 

• Medicaid, 

• TRICARE, and 

• Veterans' benefits. 

Why would I want to buy a Medigap policy? 

You may want to buy a Medigap policy because Medicare doesn't 
pay for all of your health care. There are "gaps" or 
"out-of-pocket" costs that you must pay in the Original Medicare 
Plan. The chart on the next page gives some examples of these 
gaps. A Medigap policy will cover some, but not all of the gaps in 
the Original Medicare Plan. 

If you are in the Original Medicare Plan, a Medigap policy might 
help you 

• lower your out-of-pocket costs, and 

• get more health insurance coverage. 



14 



Section 3: What You Need to Know About Medigap Policies 



Some Examples of Gaps in Medicare-covered Services 


What YOU Pay in 2005 A Medigap 
(These amounts can change each year.) policy may help 

pay these costs 


For each benefit period, YOU PAY 

• $912 for the first 60 days 
Hospital Stays . $228 per day for days 61 _ 90 

• $456 per day for days 91-150 


/ 


For each benefit period, YOU PAY 
Skilled Nursing . Nothing for the first 2 o days 
Facility Stays . Up to $ 1 14 per day for days 2 1 - 1 00 


/ 


Blood YOU PAY the cost of the first three pints. 


/ 


Medicare 

Part B Yearly YOU PAY the $1 10 per year deductible. 

Deductible 


/ 


YOU PAY 
Medicare * 20% of the Medicare-approved amount 
Part B for most covered services 
Covered • 50% of the Medicare-approved amount 
Services for outpatient mental health treatment* 

• Copayment for outpatient hospital services 


/ 



* Medigap Plans A through J must pay 50% coinsurance for outpatient 
mental health treatment services. This percentage is different for Medigap 
Plans K and L. 



Some Medigap policies also cover other extra benefits that aren't covered by 
Medicare. Some examples of these benefits include 

• routine yearly check-ups (Beginning in 2005, Medicare covers a one-time 
"Welcome to Medicare" physical exam within the first six months of 
having Medicare Part B.), 

• Medicare Part B excess charges (the difference between your doctor's 
charge and the Medicare-approved amount) that only apply if your doctor 
doesn't accept assignment, 

• And more (see pages 20-21). 



15 



■■ 







eaigap roncies 



Who can buy a Medigap policy? 

To buy a Medigap policy, you generally must have Medicare Part A and 
Part B. You are guaranteed the right to buy a Medigap policy if you are 

• in your Medigap open enrollment period (see page 26), or 

• covered under a Medigap protection (see pages 54-63). 

You might not be able to buy a Medigap policy if you 

• are in a Medicare Advantage Plan (like an HMO, PPO, or PFFS). 

• have Medicaid. 

• already have a Medigap policy (unless you are 
cancelling your old Medigap policy). 

• are under age 65 and you are disabled or have 
End-Stage Renal Disease (ESRD). 

If you are under age 65, you might not be able to buy a Medigap policy 
until you turn age 65. More information about Medigap policies for people 
under age 65 starts on page 65. 

Can I keep seeing the same doctor if I buy a 
Medigap policy? 

In most cases, yes. If you are in the Original Medicare Plan and you have a 
Medigap policy, you can go to any doctor, hospital, or other health care 
provider who accepts Medicare. However, if you have the type of Medigap 
policy called Medicare SELECT , you must use specific hospitals and, in 
some cases, specific doctors to get your full insurance benefits. 

What is Medicare SELECT? 

Medicare SELECT is a type of Medigap policy sold in some states. If you 
buy a Medicare SELECT policy, you are buying one of the 12 standardized 
Medigap Plans A through L. With a Medicare SELECT policy, you must 
use specific hospitals and, in some cases, specific doctors to get full 
insurance benefits (except in an emergency). For this reason, Medicare 
SELECT policies generally cost less than other Medigap policies. 

What are some examples of things that are NOT 
covered by Medigap policies? 

• Long-term care , 

• Vision or dental care, 

• Hearing aids, or 

• Private-duty nursing. 



16 



Section 3: What You Need to Know About Medigap Policies 



How do Medigap Plans A through J differ from Medigap 
Plans K and L? 

Medigap Plans A through J offer different benefits than Medigap Plans K and L and cost more 
because they provide more benefits and have lower out-of-pocket costs. Listed below is a quick 
look at how Medigap Plans A through J differ from Plans K and L. 




Comparing Medigap Policies 




Medigap Plans A through J 


Medigap Plans K and L 


Premiums 


Higher premiums 


Lower premiums 


Out-of-pocket 
costs 


Lower (or no) out-of-pocket costs 


Higher out-of-pocket costs, 
but subject to out-of-pocket 
annual limits (see page 1 9) 


Basic Benefits 


Includes 


Includes 




• Medicare Part A coinsurance 
and hospital benefits 


• Medicare Part A coinsurance 
and hospital benefits 




• Medicare Part B coinsurance 


• Medicare Part B coinsurance 




or copayment 


or copayment 




• Blood 


• Blood 

• Hospice care 




See page 1 8 for details about these 
basic benefits. 


See page 19 for details about 
these basic benefits. 


Extra Benefits 


May include 
• Skilled Nursing Facility 
Coinsurance 


May include 
• Skilled Nursing Facility 
Coinsurance 




• Medicare Part A and B deductibles 


• Medicare Part A Deductible 




• Part B Excess Charges 


- 




• Foreign Travel Emergency 






• At-Home Recovery 






• Drug Coverage 
(until January 1, 2006) 






• Preventive Care 






See page 20 for details about these 
extra benefits. 


See page 2 1 for details about 
these extra benefits. 



On the next four pages, you will see four different charts. These charts are side -by-side 
to help you compare the different types of benefits that each Medigap policy offers. The 
charts on pages 18-19 will help you compare the different basic benefits for Medigap 
Plans A through J with Medigap Plans K and L. See pages 20-2 1 to compare the 
different extra benefits for Medigap Plans A through J with Medigap Plans K and L. 



17 



/i 



Section 3: What You Need to Know About Medigap Policies 



What do Medigap policies cover? 

Each standardized Medigap policy must cover basic benefits. 
Medigap Plans A through J have one set of basic benefits, and 
Plans K and L have a different set of basic benefits (see the basic 
benefits charts below for Plans A through J and page 1 9 for Plans K 
and L). Most Medigap policies pay some, if not all, of the Original 
Medicare Plan coinsurance and outpatient copayment amounts. 
These policies may also cover Original Medicare Plan deductibles. 
Some Medigap policies cover extra benefits to help pay for things 
Medicare doesn't cover (see the extra benefits charts on page 20 for 
Plans B through J and page 2 1 for Plans K and L). 



If you live in 
Massachusetts, 
Minnesota, or 
Wisconsin, see 
pages 80-82. 



Note: Medigap Plans F and J have a high-deductible option (see 
page 24). If you choose this option, you must pay the deductible first 
before the Medigap policy pays anything. 



A Quick Look at the 
Basic Benefits for Medigap Plans A through J 


Basic benefit What Medigap Plans A through J pay in 2005 

(These amounts can change each year.) 


Medicare Part A 
coinsurance and 
hospital benefits 


Plans A through J pay 

• $228 per day for days 61-90 of a hospital stay 

• $456 per day for days 91-150 of a hospital stay 

• Up to 365 more days for hospital stays during your lifetime 
after you use all Medicare hospital benefits 


Medicare Part B 
coinsurance or 
copayment 


Plans A through J pay all coinsurance and copayment 
amounts after you meet the Part B $1 10 yearly deductible. 


Blood 


Plans A through J pay for the first three pints of blood or equal 
amounts of packed red blood cells per calendar year, unless you 
or someone else donates blood to replace what you use. 



See pages 20, 43, and 46-47 for more information about Medigap Plans A through J. 



18 






Section 3: What You Need to Know About Medigap Policies 



A Quick Look at the 
Basic Benefits for Medigap Plans K and L 


Basic benefit What Medigap Plans K and L pay in 2005 

(These amounts can change each year.) 


Medicare Part A 
coinsurance and 
hospital benefits 


Plan K and Plan L pay 

• $228 per day for days 61-90 of a hospital stay 

• $456 per day for days 91-150 of a hospital stay 

• Up to 365 more days of a hospital stay during your 
lifetime after you use all Medicare hospital benefits 


Medicare Part B 
coinsurance or 
copayment 


Plan K pays 50% Part B coinsurance after you meet the 

Part B $1 10 yearly deductible. 

It pays 100% coinsurance for Part B preventive services. 

Plan L pays 75% Part B coinsurance after you meet the 

Part B $1 10 yearly deductible. 

It pays 100% coinsurance for Part B preventive services. 


Blood 


Plan K pays 50% of the first three pints of blood or 
equal amounts of packed red blood cells per calendar 
year, unless you or someone else donates blood to 
replace what you use. 

Plan L pays 75% of the first three pints of blood or 
equal amounts of packed red blood cells per calendar 
year, unless you or someone else donates blood to 
replace what you use. 


Hospice care 


Plan K pays 50% hospice cost-sharing for all Part A 
Medicare covered expenses and respite care. 

Plan L pays 75% hospice cost-sharing for all Part A 
Medicare covered expenses and respite care. 



Note: Plan K has a $4,000 out-of-pocket annual limit. Plan L has a $2,000 out-of-pocket 
annual limit. Once you meet the annual limit, the plan pays 100% of the Medicare Part A 
and Part B copayments and coinsurance for the rest of the calendar year. Charges from 
your doctor that exceed Medicare-approved amounts, called "excess charges" aren't 
covered and don't count toward the out-of-pocket limit. You will have to pay these excess 
charges. The out-of-pocket annual limit can increase each year because of inflation. 

See pages 21, 44-45, and 48 for more information about Medigap Plans K and L. 



19 



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| Medicare Part B j j Medicare Part B i j Medicare Part B 
Deductible Deductible Deductible 


i Medicare Part B j Medicare Part B 1 i Medicare Part B i Medicare Part B 
i Excess Charges I Excess Charges i i Excess Charges i Excess Charges 
(100%) (80%) (100%) (100%) 


Foreign Foreign Foreign Foreign Foreign Foreign Foreign Foreign 

Travel Travel Travel Travel Travel Travel Travel Travel 

Emergency Emergency Emergency Emergency Emergency Emergency Emergency Emergency 


At-Home At-Home At-Home At-Home 
Recovery Recovery Recovery Recovery 


Basic Basic ! Extended Drug 
Drug Benefit Drug Benefit Benefit 
j ($1,250 Limit)**! ($1,250 Limit)** i($3,000 Limit)** 


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21 



Section 3: What You Need to Know About Medigap Policies 



How much do Medigap policies cost? 

The cost of Medigap policies can vary widely. There can be big 
differences in the premiums that insurance companies charge 
for exactly the same coverage. As you shop for a Medigap policy, 
be sure you are comparing the same Medigap policy (for example, 
compare a Plan A from one company with Plan A from another 
company). Although this Guide can't give actual costs of Medigap 
policies, you can get this information by calling insurance 
companies, or by visiting www.medicare.gov on the web. Select 
"Search Tools" at the top of the page. See page 49 for more details. 
Or, you can call your State Health Insurance Assistance Program 
(see pages 85-86). 

How do insurance companies set the price of 
Medigap policies? 

Each insurance company sets its own premiums. It is important to 
ask how an insurance company prices Medigap policies. How they 
set the price affects how much you pay now and in the future. 
Medigap policies can be priced or "rated" in three ways: 

1 . Community-rated (or "no-age-rated") 

2. Issue-age-rated 

3. Attained-age-rated 

Each of these ways of pricing policies is described in the chart on 
the next page. Monthly premiums may vary by insurance company 
and by Medigap policy. The amounts in the examples aren't actual 
costs. Only you can choose the insurance company that best meets 
your needs. Remember, you should look at how much the policy 
will cost you now and in the future. 



22 



Section 3: What You Need to Know About Medigap Policies 


^^ 


How Insurance Companies set prices for Medigap Policies 


, Type of How it's 


What pricing may Examples 


1 pricing priced 


mean for you 


r 

Community- 


The same 


Premiums are the same no 


Mr. Smith is 65. He buys a 


rated 


monthly 


matter how old you are, and 


Medigap policy and pays a $165 


(also called 


premium is 


won't change except for 


monthly premium. 


no-age-rated) 


charged to 


inflation. 






! 


everyone who 




Mrs. Perez is 72. She buys the same 




has the 




Medigap policy as Mr. Smith. She 




Medigap 




also pays a $165 monthly premium 




policy, 




because with this type of policy, 




regardless 




everyone pays the same price, 




of age. 




regardless of age. 


Issue-age- 


The premium 


Premiums are lower for 


Mr. Han is 65. He buys a Medigap 


rated 


is based on the 


younger buyers, and won't 


policy and pays a $145 monthly 




age you are 


change except for 


premium. 


: 


when you buy 


inflation. 








(are "issued") 




Mrs. Wright is 72. She buys the same 




the Medigap 




Medigap policy as Mr. Han. Since 




policy. 




she is older at the time she buys it, 


1 






her monthly premium is $175. 


Attained-age- 


The premium 


Premiums for these 


Mrs. Anderson buys a Medigap 


rated 


is based on 


Medigap policies are low 


policy at age 65. She pays a $165 




your current 


for younger buyers, but go 


monthly premium. Her premium 




age (the age 


up every year and can 


will go up every year. 




you have 


eventually become the 


• At age 66, her premium goes 




"attained") so 


most expensive. They may 


up to $171 




your premium 
goes up each 


also go up because of 
inflation. 


• At age 67, her premium goes 
up to $177 




year. 




• At age 72, her premium goes 
up to $189 


Mr. Dodd buys his Medigap policy 








at age 72. He pays a $175 monthly 








premium. His premium is higher 








than Mrs. Anderson's because it is 








based on his current age. Mr. Dodd's 








premium will go up every year. 








• At age 73, his premium goes 
up to $185 

• At age 74, his premium goes 
up to $190 




Note: Look at page 32 if you are thinking about switching Medigap policies to save money. 



23 









Section 3: What You Need to Know About Medigap Policies 



Words in green 
are defined on 
pages 88-91. 



Are there factors other than age that may affect the 
cost of my Medigap policy? 

Yes. The cost of your Medigap policy may be affected 

• By Discounts: Insurance companies may offer discounts to 
females, non-smokers, and/or married people. 

• By Medical Underwriting: Some insurance companies may use 
medical underwriting. This means that you must answer medical 
questions on an application. Fill the application out carefully and 
completely. The insurance company uses this information to 
decide whether to sell you a Medigap policy, how much they will 
charge you, and whether you will have to wait for coverage to 
start. Some companies may add a waiting period for pre-existing 
conditions if your state law allows (see page 29). 

Insurance companies can't use medical underwriting if you are in 
your Medigap open enrollment period (see pages 26-28) or if 
you have special rights (called Medigap protections) to buy a 
Medigap policy (see pages 54-63). 

• If you buy a high-deductible option: Insurance companies may 
offer a "high-deductible option" on Medigap Plans F and J 

(see chart on page 20). If you choose this option, you must pay 
the first $1,730 (the deductible in 2005) in Medigap-covered 
costs before the Medigap policy pays anything. This amount can 
change each year. 

High-deductible policies often have lower premiums, but if you 
need a lot of Medicare-covered health care services, supplies, 
and equipment, your out-of-pocket costs will be higher, and you 
may not be able to change to another Medigap policy. 

In addition to the $1,730 (in 2005) deductible that you must pay 
for the high-deductible option for Plans F and J, you must also 
pay deductibles for 

■ Prescription drugs ($250 per year for Plan J only, because 
Plan F doesn't cover prescription drugs), and 

■ Foreign travel emergency ($250 per year for Plans F and J). 



24 



Section 3: What You Need to Know About Medigap Policies 



Words in green 
are defined on 
pages 88-91. 



Are there factors other than age that may affect the 
cost of my Medigap policy? (continued) 

• If you buy a Medicare SELECT policy: Medicare SELECT 
is a type of Medigap policy sold by some insurance 
companies in some states. If you buy a Medicare SELECT 
policy, you are buying one of the 12 standardized Medigap 
Plans A through L. Medicare SELECT policies require you to 
use specific hospitals and, in some cases, specific doctors to 
get full insurance benefits (except in an emergency). 
Generally, Medicare SELECT policies cost less than other 
Medigap policies. 

If you have a Medicare SELECT policy and you don't use a 
Medicare SELECT hospital or doctor for non-emergency 
services, your costs will be higher. You will have to pay some 
or all of what Medicare doesn't pay. Medicare will pay its 
share of approved charges no matter which hospital or doctor 
you choose. 



m 



25 



Section 3: What You Need 



out Medigap Policies 



Words in green 
are defined on 
pages 88-91. 



When is the best time to buy a Medigap policy? 

The best time to buy a Medigap policy is during your Medigap 
open enrollment period. 

Your Medigap open enrollment period lasts for six months. It 
starts on the first day of the month in which you are both 

• age 65 or older, and 

• enrolled in Medicare Part B. 

Once your six-month Medigap open enrollment period starts, 
it can't be changed. 

During this period, an insurance company can't 

• deny you any Medigap policy it sells, 

• make you wait for coverage to start, or 

• charge you more for a policy because of your 
health problems. 

If you buy a Medigap policy during your Medigap open 
enrollment period, in many cases the insurance company must 
shorten the waiting period for pre-existing conditions (see page 29) 
if you had recent health coverage. This is called "creditable 
coverage" (see page 30). 

If you are eligible for Medicare because you're disabled or have 
End-Stage Renal Disease (ESRD), see pages 65-68. 

Note: You may want to apply for a Medigap policy before your 
Medigap open enrollment period starts if you are losing coverage 
because you are eligible for Medicare. This will allow you to have 
continuous coverage. 

How can I tell if I'm in my Medigap open 
enrollment period? 

You can tell if you are in your Medigap open enrollment period 
by looking at your red, white, and blue Medicare card (see sample 
card on the next page). The lower right corner of this card shows 
the dates that your Medicare Part A and Part B coverage started. 
If you are age 65 or older, add six months to the date that your 
Medicare Part B coverage starts. If that date is in the future, you 
are still in your Medigap open enrollment period. If that date is in 
the past, you have missed your Medigap open enrollment period 
(see example on the next page). 



26 




M51IUEEB1S1 



now 



WISHllfiEIS 




1-800-MEDICARE (1-800-633-4227) 

NAME OF BENEFICIARY 

JANE DOE 

MEDICARE CLAIM NUMBER ^EX^f^^ 

000-Q0-0G00-A FEMALE 

S ENTITLED TCfr* ^LlmFE(»E DATE 

ITAL (PART A) 07-01-1986 

CAL^(PARTB) 07-01-1986 




HOSPIT 
MEDIC/ 

SIGN^^ 
HERE _ 




gggf^ 




Note: There are earlier 
versions of this card that 
are slightly different. 
They are still valid. 



Example: Medigap Open Enrollment Period 



It is October 1, 2005, and Mr. Rodriguez (age 65) wants to 
buy a Medigap policy. He needs to know if he is in his 
Medigap open enrollment period. He looks at his Medicare 
card. His Medicare Part B coverage started August 1, 2005. 
To figure out if he is in his open enrollment period, he must 
add six months to his Medicare Part B start date and see if it 
is before or after the current date. 

August 1, 2005 + six months = February 1, 2006 

Since it is October 1, 2005, he is still in his open enrollment 
period. Mr. Rodriguez has until January 31, 2006, to buy a 
Medigap policy during his Medigap open enrollment period. 

Although Mr. Rodriquez has until January 3 1 , 2006 to buy a 
Medigap policy, he won't be able to buy a Medigap policy 
with prescription drug coverage after December 31, 2005. 



What if I missed my Medigap open 
enrollment period? 

If you apply for a Medigap policy after your open enrollment 
period has ended, the Medigap insurance company is allowed to 
use medical underwriting (see page 24) to decide whether to 
accept your application, and how much to charge you for the 
policy. If you are in good health, the insurance company is likely 
to sell you the policy, but there is no guarantee that they will 
(unless you become eligible for one of the Medigap protections 
listed on page 55). Remember, not all insurance companies use 
medical underwriting. 



27 



Section 3: What You Need to Know About Medigap Policies 



I am over age 65 and still working (or covered 
under my spouse's health plan). Should I enroll in 
Medicare Part B and start my Medigap open 
enrollment period? 

If you or your spouse is working and have group health coverage 
through an employer or union, your Medigap open enrollment 
period won't start until you sign up for Medicare Part B. 

So you may want to wait to enroll in Medicare Part B. Remember, 
once you're age 65 or older and enrolled in Medicare Part B, your 
Medigap open enrollment period starts and can't be changed. 

However, if your employer group health plan only pays after 
Medicare pays, your plan can require you to enroll in Medicare 
Part B in order to get benefits under that plan. 

Important information about enrolling in 
Medicare Part B 

If you don't enroll in Medicare Part B when you are first eligible or 
after you drop employer coverage, you may have to pay a higher 
monthly premium. You will have to pay this extra amount as long 
as you have Medicare Part B. 

There are three times when you can enroll in Medicare Part B. 
These are called: 

1 . Initial Enrollment Period 

2. General Enrollment Period 

3. Special Enrollment Period 

It's very important to learn about these enrollment periods. 

For more information about these enrollment periods, get a free 
copy of "Enrolling in Medicare" (CMS Pub. No. 1 1036) at 
www.medicare.gov on the web. Select "Search Tools" at the top of 
the page. Or, call 1-800-MEDICARE (1-800-633-4227). TTY 
users should call 1-877-486-2048. 



28 



Words in green 
are defined on 
pages 88-91. 




Pre-existing conditions 

What is a pre-existing condition? 

A pre-existing condition is a health problem you had before the 
date a new insurance policy starts. 

Will my pre-existing condition be covered if I buy 
a Medigap policy? 

It depends. In some cases, if you have a health problem before 
your Medigap policy started, a Medigap insurance company can 
refuse to cover that health problem for up to six months. This is 
called a "pre-existing condition waiting period." The insurance 
company can only use this kind of waiting period if your health 
problem was diagnosed or treated during the six months before 
the Medigap policy started. This means that the insurance 
company can't make you wait for coverage of your condition just 
because it thinks you should have known to see a doctor. 

• During your Medigap open enrollment period 

If you buy a Medigap policy during your Medigap open 
enrollment period, and you had at least six months of 
previous health coverage that qualifies as "creditable coverage" 
(see page 30), the company can't apply a pre-existing 
condition waiting period to you. If you had less than six 
months of creditable coverage, this waiting period will be 
reduced by the number of months of creditable coverage 
you had. 

• When you have special Medigap protections 
(Guaranteed Issue Rights) 

If you buy a Medigap policy when you have special Medigap 
protections (also called guaranteed issue rights), the 
insurance company can't use a pre-existing condition waiting 
period. For more information about Medigap protections, see 
pages 54-63. 

If you want to know if you will have a pre-existing condition 
waiting period if you switch Medigap policies, see page 32. 



29 



an 



Section 3: What You Need to Know About Medigap Policies 



Creditable coverage 

What is creditable coverage? 

Creditable coverage (for Medigap policies) is generally any other 
health coverage you had before you apply for a Medigap policy. 

These types of health care coverage may count as creditable 
coverage for Medigap policies: 

• A group health plan (like an employer or union plan) 

• A health insurance policy 

• Medicare Part A or Medicare Part B 

• Medicaid (see pages 74-75) 

• A medical program of the Indian Health Service or tribal 
organization 

• A state health benefits risk pool (sometimes called a state 
high risk pool) 

• TRICARE (the health care program for military dependents 
and retirees, see page 76) 

• A Federal Employees Health Benefit plan 

• A public health plan 

• A health plan under the Peace Corps Act 

• COBRA (see pages 71-72) 

Important: Whether you had creditable coverage depends on 
whether you had any "breaks in coverage" — when you were 
without any of these kinds of health coverage for more than 63 
days in a row. You can only count creditable coverage that you had 
after that break in coverage. If you have had one or more breaks in 
coverage, but each break was shorter than 63 days, then you can 
add the periods of coverage together. This will count towards your 
creditable coverage. 

The following doesn't count as creditable coverage: 

• Hospital indemnity insurance 

• Specified disease insurance (like cancer insurance) 

• Vision or dental policies 

• Long-term care policies 



30 



Section 3: 



YiraaY^r^d.llUWfJ.l.llll'.ffT 




What is creditable coverage? (continued) 



Example: Creditable Coverage 



Mr. Smith is 65 and is being treated for heart disease. His 
Medicare Part A and Part B started November 1, 2004. Before this 
date, he had no health insurance coverage. 

On March 1, 2005, Mr. Smith buys a Medigap policy. His 
Medigap insurance company refuses to cover his heart disease 
condition for six months (the pre-existing condition waiting 
period). However, since Mr. Smith had Medicare Part A and Part B 
from November 1 to March 1, the insurance company must use his 
four months of Medicare coverage as creditable coverage to 
shorten this six-month waiting period. 

Now his waiting period will only be two months instead of six 
months. During these two months, after Medicare pays its share, 
Mr. Smith will have to pay the rest of the costs for the care of his 
heart disease. He will also have to pay his Medigap premiums. 
The Medigap policy will pay for other covered care. 



31 






Section 3: What You Need to Know About Medigap Policies 



Switching Medigap policies 

What if I have an old Medigap policy and I want 
to switch to a different Medigap policy? 

You may not have a guaranteed right to switch Medigap policies. 
But, if you are given the opportunity, make sure you compare 
benefits and premiums before switching policies. If you bought 
your Medigap policy before 1992, it may offer better coverage 
than a newer policy. On the other hand, older Medigap policies 
may have bigger premium increases than newer standardized 
Medigap policies currently being sold. 



Words in green 
are defined on 
pages 88-91. 



If you decide to switch, don't cancel your first Medigap policy until 
you have decided to keep the second Medigap policy. You have 30 
days to decide if you want to keep the new Medigap policy. This is 
called your "free look" period. The 30-day free look period starts 
when your Medigap policy is issued to you. 

Do I have to switch Medigap policies if I have an 
older Medigap policy? 

No. If you have an older Medigap policy that you bought before 
1992, you can generally keep it. You don't have to switch to one 
of the standardized Medigap policies. But, if you decide to buy a 
newer Medigap policy, you won't be able to go back to your old 
Medigap policy. 

Do I have to wait a certain length of time before I 
can switch to a different Medigap policy? 

No, but your new Medigap policy might not cover all your 
pre-existing conditions if you've had your current Medigap policy 
for less than six months. However, the amount of time you've had 
your current Medigap policy must count towards the amount of 
time you must wait before your new policy covers your 
pre-existing condition. 

If the new Medigap policy has a benefit that wasn't in your old 
policy, the company can make you wait up to six months before 
covering you for that benefit. 



32 




Words in green 
are defined on 
pages 88-91. 



■VTFllfifl 5 ! 



Losing Medigap coverage 

Can my Medigap insurance company drop me? 

In most cases, no. If you bought your Medigap policy after 1990, 
the policy is guaranteed renewable. This means your insurance 
company can drop you only if 

• you stop paying your premium, 

• you aren't truthful about something under the policy, or 

• the insurance company goes bankrupt. 

For more information, see Medigap Protections, Situation #6 on 
page 60. 

Insurance companies in some states may be able to drop you if you 
bought your policy before 1990. For an insurance company to 
refuse to renew one of these older Medigap policies, the company 
must get the state's approval. If this happens, you have the right to 
buy another Medigap policy (see Medigap Protections, Situation 
#6 on page 60). 



33 



Section 3: What You Need to Know About Medigap Policies 



Words in green 
are defined on 
pages 88-91. 



How your bills get paid 

Does the Medigap insurance company pay my 
doctor directly? 

Most Medigap insurance companies get information about your bills 
directly from Medicare. 

However, if your Medigap insurance company doesn't have this 
service, ask your doctors if they accept "assignment" for their 
Medicare patients. If your doctor does accept assignment, then ask 
their staff to put on the Medicare claim form that you want Medigap 
insurance benefits paid to the doctor. You will need to sign the claim 
form or have your doctor keep your signature on record. Make sure 
this information is correct. 

When these conditions are met, Medicare will process the claim and 
send it to your Medigap insurance company. Your Medigap 
insurance company will pay your doctor directly and then send you 
a notice. If you don't get this notice, you may ask for it from your 
Medigap insurance company. 

If the Medigap insurance company doesn't pay your doctor directly, 
you should report this to your State Insurance Department (see 
pages 85-86). For more information on Medigap claim filing by 
Medicare, call 1-800-MEDICARE (1-800-633-4227). TTY users 
should call 1-877-486-2048. 



34 






; 



ecuon 



now 



eaigap policies 



Watch out for illegal insurance practices 

It is illegal for anyone to 

• pressure you into buying a Medigap policy, or lie or mislead 
you to switch from one company or policy to another. 

• sell you a second Medigap policy when they know that you 
already have one, unless you tell the insurance company in 
writing that you plan to cancel your existing Medigap policy. 

• sell you a Medigap policy if they know you have Medicaid, 
except in certain situations (see page 75). 

• sell you a Medigap policy if they know you are in a Medicare 
Advantage Plan. 

• claim that a Medigap policy is part of the Medicare Program 
or any other Federal program. Remember, Medigap is private 
health insurance. 

• sell you a Medigap policy that can't legally be sold in your 
state. Check with your State Insurance Department (see 
pages 85-86) to make sure that the Medigap plan you are 
interested in can be sold in your state. 

• sell you a Medigap policy with prescription drug coverage 
after December 31, 2005. 

• misuse the names, letters, or symbols of the U. S. Department 
of Health and Human Services (HHS), Social Security 
Administration (SSA), Centers for Medicare & Medicaid 
Services (CMS), or any of their various programs like 
Medicare. (For example, suggesting the Medigap policy has 
been approved or recommended by the Federal government.) 

• claim to be a Medicare representative. 

If you believe that a Federal law has been broken, call the Inspector 
General's hotline at 1-800-HHS-TIPS (1-800-447-8477). In most 
cases, however, your State Insurance Department can help you with 
insurance-related problems (see pages 85-86). 




35 



.' ■ 



. . ■ ;■■"',; ""'•■; 






Section 3: What You Need to Know About Medigap Policies 



Ways to check if an insurance company 
is reliable 

To help you find out if an insurance company is reliable, you can take 
the following actions: 

• Call the State Insurance Department in your state (see pages 
85-86). Ask if they keep a record of complaints against insurance 
companies and ask whether these can be shared with you. 

• Call the State Health Insurance Assistance Program in your state 
(see pages 85-86). These programs can give you free help with 
choosing a Medigap policy. 

• Go to your local public library. Your local public library can 
help you 

■ get information on an insurance company's financial 
strength by independent rating services such as, 

Weiss Rating, Inc., A.M. Best, and Standard & Poors, and 

■ look at information on the web. 



Words in green 
are defined on 
pages 88-91. 



Talk to someone you trust, like a family member, your insurance 
agent, or a friend who has a Medigap policy. 



36 



section 




Prescription 
Drug 

Coverage 
Overview 



This section 

'explains new Medicare^ 

prescription drug plans 

and changes to 

Medigap policies with 

prescription drug 

coverage. 



W 



4l 



Section 4: Prescription Drug Coverage Overview 



Words in green 
are defined on 
pages 88-91. 



If you have a Medigap policy with prescription drug coverage, you 
should read this section carefully. 

Medicare prescription drug plans 

Beginning January 1, 2006, new Medicare prescription drug plans 
will be available to people with Medicare. Insurance companies 
and other private companies are working with Medicare to offer 
these Medicare prescription drug plans. 

When the new Medicare prescription drug plans become available, 
the rules about prescription drug coverage under Medigap policies 
will change. 

Note: If your prescription drug coverage is through a Medigap 
policy, see "Medigap policies and Medicare prescription drug 
plans" on pages 39-40 and Situation #8 on page 62. 

The new Medicare prescription drug plans might be a good choice 
for you. For information about Medicare prescription drug plans, 
you can 

• look in the "Medicare & You 2006" handbook (CMS Pub. 
No. 10050). This handbook is mailed to people with Medicare 
every fall. 

• visit www.medicare.gov on the web. Note: In late fall 2005, 
you will be able to get personalized Medicare prescription 
drug plan information for your area from this website. 

• call 1-800-MEDICARE (1-800-633-4227). A customer service 
representative can answer your Medicare questions and help 
compare Medicare prescription drug plans, when they become 
available. TTY users should call 1-877-486-2048. 

• call your State Health Insurance Assistance Program (SHIP) 
(see pages 85-86). Your SHIP can provide one-on-one help 
comparing your health insurance options. 



38 



ection 4: Prescription Drug Coverage Overview 



Medigap policies and Medicare prescription drug plans 

I have a Medigap policy with prescription drug coverage. How does the 
new Medicare prescription drug coverage affect my Medigap policy? 

If your Medigap policy covers prescription drugs, sometime between September 15, 2005 
and November 15, 2005, your Medigap insurance company will mail you information 
describing how the new Medicare prescription drug coverage will affect your Medigap 
policy. When you get this notice, make sure you read it carefully before making any 
decisions. Here is a summary of what the notice will tell you. 




Option Situation What You Need to Do or Know 


1 


You can enroll in a 
Medicare prescription 
drug plan and keep your 
Medigap policy with the 
prescription drug 
coverage removed. 


• Enroll in a Medicare prescription drug plan that 
meets your needs. 

• Tell your Medigap insurance company when your 
Medicare prescription drug plan starts. 

• You will no longer get prescription drug coverage 
under your Medigap policy and your premium will 
be adjusted based on this change. 


2 


You can enroll in a 
Medicare prescription 
drug plan by May 15, 
2006 and buy a different 
Medigap policy without 
prescription drug coverage. 


• Enroll in a Medicare prescription drug plan that 
meets your needs. 

• Contact your Medigap insurance company and 
fmd out which other Medigap policy you can buy. 
See Situation #8 on page 62 for information about 
your right to buy the Medigap policy. 


3 


You can enroll by 
May 15, 2006 in a 
Medicare Advantage Plan 
that includes prescription 
drug coverage. 


• Enroll in a Medicare Advantage Plan that meets 
your needs. 

• Tell your Medigap insurance company if you 
enrolled in a Medicare Advantage Plan. You won't 
need your Medigap policy. Remember, Medigap 
policies won't work with Medicare Advantage Plans. 


4 


You can keep your 
Medigap policy without 
any changes. 


• You don't need to do anything. 

• Your Medigap premium could increase more 
quickly than in the past. 

• Keep in mind, if you change your mind and enroll 
in a Medicare prescription drug plan after May 15, 
2006, you may have to permanently pay more for 
your Medicare prescription drug plan or Medicare 
Advantage prescription drug premium and you 
will lose vour right to switch to another policy. 



To learn more about your options, look for more information in the mail from your Medigap 
insurance company or call your State Health Insurance Assistance Program (see pages 85-86). 



39 



Section 4: Prescription Drug Coverage Overview 



Medigap policies and Medicare prescription drug 
plans (continued) 

How does my Medigap prescription drug coverage 
compare to a Medicare prescription drug plan? 

On average, most Medigap prescription drug coverage won't cover as 
much as a Medicare prescription drug plan. Unless your Medigap 
policy is one of a few that are found to be "at least as good as" 
Medicare coverage and if you don't join a Medicare prescription drug 
plan when you are first eligible (November 15, 2005 through 
May 15, 2006), you may have to pay more to join later. Your 
prescription drug plan premium cost will go up at least 1% per 
month for every month that you wait to enroll and don't have 
coverage at least as good as standard Medicare prescription drug 
coverage. You will have to pay this extra amount for as long as you 
have Medicare prescription drug coverage. You may also have to wait 
until November 1 5 -December 3 1 to enroll in a Medicare prescription 
drug plan and may not be able to switch to another Medigap policy. 

A Medigap policy with prescription drug coverage bought before 
mid- 1 992 may cover as much as or more than a Medicare 
prescription drug plan. Medigap policies sold in Massachusetts, 
Minnesota, and Wisconsin with prescription coverage may also cover 
as much as or more than a Medicare prescription drug plan. 

You will get a notice from your Medigap insurance company that 
tells you how your Medigap policy's prescription drug coverage 
compares to a Medicare prescription drug plan's coverage. If you 
have questions, you can call your Medigap insurance company or 
your State Health Insurance Assistance Program (see pages 85-86). 



40 



section 




Steps to 
Buying a 
Medigap 
Policy 



This section 

provides steps 

to help you choose 

a Medigap 

policy that's right 

for you. 






- 



Section 5: Steps to Buying a Medigap Policy 







Words in green 
are defined on 
pages 88-91. 



Steps to buying a Medigap policy 

Buying a Medigap policy is an important decision. Only you can decide 
if a Medigap policy is the right kind of health insurance coverage for 
you to supplement Medicare coverage. If you decide to buy a Medigap 
policy, shop carefully. Look for a Medigap policy that you can afford 
and that gives you the coverage you need most. As you shop for a 
Medigap policy, keep in mind that different insurance companies may 
charge different amounts for exactly the same Medigap policy, and not 
all insurance companies offer all of the Medigap policies. 

The steps to buying a Medigap policy include the following: 

STEP 1: Decide which benefits you want, then decide which of the 
Plans A through L best meet your needs (see below and 
pages 43-48). 

STEP 2: Find out which insurance companies sell Medigap 
policies in your state (see page 49). 

STEP 3: Call the insurance companies that sell the Medigap policies 
that you are interested in and compare costs (see page 50). 

STEP 4: Choose the right Medigap policy for you (see page 51). 

STEP 5: Buy the Medigap policy (see page 52). 



STEP 1 . Decide which benefits you want, then 
decide which of the Plans A through L 
best meet your needs. 



The charts on the following pages will help you compare the different 
types of benefits that each Medigap policy offers. The charts on pages 
43-45 will help you compare the basic benefits. See pages 46-48 to 
compare the extra benefits. 

Important: You should think about your current and future health care 
needs because you might not be able to switch Medigap policies later. 
As you get older, your health care needs might increase. You may also 
want to think about prescription drug coverage. Starting January 1, 2006, 
Medicare will offer prescription drug coverage for all people with 
Medicare. If you think you will need prescription drug coverage, you 
may want to enroll in a Medicare prescription drug plan. You can enroll 
in a Medicare prescription drug plan starting November 15, 2005. For 
more information about Medicare prescription drug coverage, call 
1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. 



42 



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Section 5: Steps to Buying a Medigap Policy 



STEP 2. Find out which insurance companies 
sell Medigap policies in your state. 





To find out which insurance companies sell Medigap policies in 
your state, you can do any of the following: 

• Call your State Health Insurance Assistance Program 
(see pages 85-86). Ask if they have a "Medigap rate 
comparison shopping guide" for your state. These types of 
guides usually list the insurance companies that sell Medigap 
policies in your state and compare the costs of policies from 
each insurance company. 

' Call your State Insurance Department (see pages 85-86). 

' Visit www.medicare.gov on the web. Select "Search Tools" at 

the top of the page. 

This website will help you find information on all your 
health plan options, including the Medigap policies in your 
area. You can also get information on the following: 

/ Insurance companies that sell Medigap policies in 
your state, 

j How to contact these insurance companies, 

/ What the policies must cover, and 

/ How insurance companies decide what to charge you 
for a Medigap policy premium. 

If you don't have a computer, your local library or senior 
center may be able to help you look at this information. 

• Call 1-800-MEDICARE (1-800-633-4227). A customer 
service representative will help you get information on all 
your health plan options, including the Medigap policies in 
your area. You will get your results in the mail within three 
weeks. TTY users should call 1-877-486-2048. 

You should plan to call more than one insurance company that 
sells Medigap policies in your state, since costs can vary between 
companies. Check the companies you call to be sure they are 
honest and reliable (see page 36). 



49 




Buying a Medigap Policy 



STEP 3. Call the insurance companies that sell 
the Medigap policies that you are 
interested in and compare costs. 



Call more than one insurance company and ask the questions 
listed below. Friends and relatives can tell you about their 
Medigap policies and the quality of service, but their Medigap 
policies might not fit your needs. 

Medigap Policy Comparison Worksheet 

Use this worksheet to compare costs and benefits you are considering. Make sure you get 
the names, addresses, and telephone numbers of the insurance companies and the 
agents you talk to. 



50 



Ask each insurance company... 


Company 1 


Company 2 


Are you licensed in this state? (The answer should be yes.) 






Which Medigap policies do you sell? (Insurance companies 
usually offer some, but not all, of the Medigap plans. Make sure 
they sell the plan you want.) 






What is the cost of this policy? 






What has the cost of this Medigap policy been for the past 
few years? 






How is the price decided? 

• What type of pricing does this insurance company use? 
(Community-rated, issue-age-rated, or 
attained-age-rated, see pages 22-23) 

• Is there a discount if I am a female, a non-smoker, 
or married? 






Are there any additional ("innovative") benefits or discounts 
included in this policy? 






If you aren't in your Medigap open enrollment period or in 
another situation where you have a guaranteed issue right, ask: 

• Will you accept my application? 

• Do you review my health records or application 
(medical underwriting) to decide how much to charge 
me for a Medigap policy? 

• If you have a pre-existing condition ask, "Will my 
pre-existing condition mean a delay in the start of 
my benefits?" 







1 1 



Section 5: Steps to Buying a Medigap Policy 







STEP 4. Choose the right Medigap policy for you. 



After you call the insurance companies, compare their costs, and 
check to see if the companies are reliable. Then choose the 
Medigap policy that is right for you. 

To make your final choice, you should do the following: 

• Carefully review the Medigap policy benefits to make sure 
it covers the benefits you need and want. 

• Decide if you can afford the cost of the Medigap policy. 

• Make sure you feel good about and trust the insurance 
company and/or the insurance agent. 

• If possible, talk with someone you trust, like a family 
member, friend, doctor, insurance agent, or your State 
Health Insurance Assistance Program (see pages 85-86) 
about your choice. 

Once you have done the items above, you are ready to move 
on to Step 5 (see page 52). 



51 



eps to Buying a Medigap Policy 



STEP 5. Buy the Medigap policy. 




i y 



Once you have decided on the insurance company and the 
Medigap policy you want, you can apply for your policy. The 
insurance company must give you a clearly worded summary 
of your Medigap policy when you apply. Read it carefully. 
If you don't understand it, ask questions. Remember the 
following when you buy your Medigap policy: 

• Fill out your application carefully and completely. If the 
insurance agent fills out the application, review it to make 
sure it's correct. Otherwise, answer all of the medical 
questions carefully. If you buy your Medigap policy 
during your open enrollment or guaranteed issue period, 
the insurance company can't use any medical answers you 
give them to deny you coverage or price the policy. 

• Remember, you don't need more than one Medigap policy. 
If you already have a Medigap policy, it is illegal for an 
insurance company to sell you a second policy unless you 
tell them in writing that you are going to cancel the first 
Medigap policy. However, don't cancel your old Medigap 
policy until the new one is in place, and you have decided 
to keep the new Medigap policy. Once you have received 
the new Medigap policy, you have 30 days to decide if you 
want to keep the new Medigap policy. This is called your 
"free look" period. The 30-day free look period starts 
when your Medigap policy is issued to you. 

• It is best to pay for your Medigap policy by check, money 
order, or bank draft. Make it payable to the insurance 
company, not the agent. Get a receipt with the insurance 
company's name, address, and telephone number for 
your records. 

• Ask for your Medigap policy to become effective when 
you want coverage to start, or when your old Medigap 
policy coverage ends. If, for any reason, the insurance 
company won't give you the start date you want, call your 
State Insurance Department (see pages 85-86). 

• Your insurance company is required to send you a copy of 
your policy within 30 days after you are approved. If you 
don't get your policy in 30 days, call your insurance 
company. If you don't get your policy in 60 days, call your 
State Insurance Department (see pages 85-86). 



52 




section \ % 



Medigap 
Rights and 
Protections 



Use this section to 

find out about your 

Medigap rights and 

protections. 



ction 6: Medigap Rights and Protections 






If you live in 
Massachusetts, 
Minnesota, or 
Wisconsin, you 

have the same 
guaranteed issue 
rights to buy a 
Medigap policy, 
but the policies 
are different. 
If you have 
questions, call 
your State 
Insurance 
Department 
(see pages 
85-86). 



Words in green 
are defined on 
pages 88-91. 



54 



Medigap rights and protections 
(guaranteed issue rights) 

Your rights to buy a Medigap policy 

In some situations, you have the right to buy a Medigap policy outside 
of your Medigap open enrollment period. These rights are called 
"Medigap protections." They are also called guaranteed issue rights 
because the law says that insurance companies must sell ("issue") you 
a Medigap policy even if you have health problems. 

In these situations, an insurance company 

• must sell you a Medigap policy, 

• must cover all your pre-existing conditions (see page 29), and 

• can't charge you more for a Medigap policy because of past or 
present health problems. 

In many cases, you get these protections when you have other health 
coverage that changes in some way. 

Note: If you drop your Medigap policy, you may not be able to get it 
back except in very limited cases. 

Important: In some situations, you have a guaranteed issue right to 
buy a Medigap policy if you lose certain kinds of health coverage. You 
should keep a copy of any letters, notices, and claim denials that show 
you have lost your other coverage. Be sure to keep anything that has 
your name on it. Also, keep the postmarked envelope these papers 
come in as proof of when it was mailed. You may need to send a copy 
of some or all of these papers with your application for a Medigap 
policy to prove you lost coverage and have the right to these 
Medigap protections. 

Remember, it is best to apply for a Medigap policy before your 
current health coverage has ended. You can apply for a Medigap 
policy while you are still in your health plan and choose to start your 
Medigap coverage the day after your health plan coverage ends. This 
will prevent breaks in your health coverage. 

The Medigap protections in this section are from Federal law. Many 
states provide more Medigap protections than Federal law. Your state 
might let you choose from more Medigap policies or give you a longer 
time to apply for a Medigap policy when you lose your coverage. Call 
your State Health Insurance Assistance Program or State Insurance 
Department for more information (see pages 85-86). 



' ■■"'■ .•,■"■:.'■■'■ ;■■_,■■";.-.■■■ /..; 



Section 6: Medigap Rights and Protections 



Medigap protections if you lose or drop your health care 
coverage (guaranteed issue rights) 

In order to get these Medigap protections, you must meet certain conditions listed 
below. These rights are for both Medigap and Medicare SELECT policies. 

Note: There may be times when more than one situation applies to you. When 
this happens, you can choose the Medigap protection that gives you the best 
choice of Medigap policies. 

Important: Programs of All-inclusive Care for the Elderly (PACE) is available only 
in states that choose to offer it under Medicaid. If you have Medicaid, an insurance 
company can sell you a Medigap policy only in certain situations (see page 75). 




Situation Protects you if... See 

page 


1 


You are in a Medicare health plan other than the 
Original Medicare Plan and the plan is going to leave 
the Medicare Program or stop giving care in your area. 


56 


2 


You have employer group health plan or union 
coverage that is ending. 


57 


3 


Your coverage ends because you move out of the 
plan's service area. 


58 


4 


You joined a Medicare Advantage Plan or PACE 
when you were first eligible for Medicare at age 65 
and within the first year of joining, you decide you 
want to switch to the Original Medicare Plan. 


59 


5 


You dropped a Medigap policy to join a Medicare 
Advantage Plan or PACE, or to switch to a Medicare 
SELECT policy, for the first time, you have been in 
the plan less than a year, and you want to switch back. 


60 


6 


Your Medigap insurance company goes bankrupt and 
you lose your coverage, or your Medigap policy 
coverage ends through no fault of your own. 


60 


7 


You leave a Medicare Advantage Plan, or drop a 
Medigap policy because the company hasn't followed 
the rules, or it misled you. 


61 


8 


You have a Medigap policy that covers prescription 
drugs. You want to enroll in a new Medicare 
prescription drug plan and switch to another Medigap 
policy that doesn't have prescription drug coverage. 


62 



55 



Section 6: Medigap Rights and Protections 



Medigap protections 



Programs of 
All-inclusive Care 
for the Elderly 
(PACE) combine 
medical, social, and 
long-term care 
services for frail 
people. PACE is 
available only in 
states that choose to 
offer it under 
Medicaid. For more 
information about 
PACE, see page 76. 



SITUATION #1 : You are in a Medicare health plan other than 
the Original Medicare Plan and the plan is going to leave the 
Medicare Program or stop giving care in your area. 



In this situation, your Medicare health plan or PACE provider 
sends you a letter telling you when your coverage will be ending. 
The letter will tell you if there are any other Medicare health plans 
or PACE providers in your area. If you switch to one of those you 
won't need a Medigap policy. 

However, if you decide to switch to the Original Medicare Plan 
you will have a right to buy a Medigap Plan A, B, C, or F that is 
sold in your state by any insurance company. 

You have two choices when to get your Medigap policy 

1 . Leave (disenroll from) your Medicare health plan or PACE 
any time after the day you get your letter, but before your 
coverage would have ended. You will automatically return 
to the Original Medicare Plan. You will have 63 calendar 
days from the day you leave the plan to apply for a 
Medigap policy. 

2. Stay in your Medicare health plan or PACE until the date 
your coverage ends. You will automatically return to the 
Original Medicare Plan when your coverage ends. You will 
have 63 calendar days after your health coverage ends to 

apply for a Medigap policy. 

Important: You will have additional rights under Situation #4 
(see page 59) or Situation #5 (see page 60) if 

• this was the first time you were in a Medicare Advantage Plan, 

• you were in the plan less than one year before the plan left the 
Medicare Program or stopped giving care in your area, and 

• you choose to return to the Original Medicare Plan and apply 
for a Medigap policy. 

If instead you immediately join another Medicare Advantage Plan, 
you can stay in that plan for up to one year and still have the 
rights described in Situations #4 and #5. 



56 



Section 6: Medigap Rights and Protections 



Medigap protections (continued) 



SITUATION #2: You have employer group health plan or union 
coverage that is ending. 



In this situation, you are in the Original Medicare Plan and you also 
have coverage from an employer group health plan or union. If your 
coverage is from your (or spouse's) current employment, the plan 
probably pays first, and Medicare pays second. If your coverage is 
retiree coverage, Medicare probably pays first, and your plan pays 
second. Here are your rights under Federal law if you are in a plan 
that pays second, and 

• the employer goes out of business, 

• the employer stops offering the health plan, or 

• you are no longer eligible for the health plan (for example, if the 
coverage is from your spouse, and you get divorced or your 
spouse dies). 

There are two ways you might find out that your employer group 
health or union coverage is ending 

• the employer or union, the health plan, or the insurance company 
will send you a notice telling you the coverage is ending, or 

• no one will send a notice in advance, but you will get a claim 
denial notice letting you know that a claim has been denied. 

Important: Keep the notice or claim denial that has your name 
on it. This will help prove that you lost coverage. 

In this situation, you have the right to buy a Medigap Plan A, B, C, 
or F that is sold in your state by any insurance company. 

You must apply for the Medigap policy within 63 calendar days after 
the date the coverage ends, or the date on your notice, or the date on 
your claim denial — whichever is later. 

Note: In this situation, state laws may vary. If you lose coverage 
under an employer group health plan that pays before Medicare, state 
law might give you a right to buy a Medigap policy. If the employer 
offers you "COBRA" coverage (see pages 71-72) you can either buy 
a Medigap policy now, or you can wait until the COBRA coverage 
ends and then you will have another right to buy a Medigap policy. 
For more information, call your State Health Insurance Assistance 
Program (see page 85-86). 



57 



ection 




BMfiEBtPETilMIS 



roiections 




Words in green 
are defined on 
pages 88-91. 



Medigap protections (continued) 



SITUATION #3: Your coverage ends because you move out of 
the plan's service area. 



If you have health coverage from a Medicare Advantage Plan or you 
are in PACE, and you move out of the plan's service area, you will 
have to end your coverage. 

If you have a Medicare SELECT policy, you can keep your policy 
because it is guaranteed renewable. However, because you have 
moved, you may not be able to use hospitals or other health care 
providers that are on the policy's list of approved providers. This is 
called the policy's "network." Therefore, you might want to switch to 
another Medigap policy. 

You have the right to buy a Medigap Plan A, B, C, or F that is sold by 
any insurance company in your state (if you move within the same 
state but outside of the plan's service area), or the state you are moving 
to (if you move out of state). 

You must tell your current plan that you are moving and give them a 
date when you will end your coverage. You can apply for a Medigap 
policy as early as 60 calendar days before the date your health 
coverage ends. You must apply for a Medigap policy no later than 63 
calendar days after your health coverage ends to get this protection. 



58 



ecxion 



ap Rights 



Medigap protections (continued) 



SITUATION #4: You joined a Medicare Advantage Plan or 
PACE when you were first eligible for Medicare at age 65 and 
within the first year of joining, you decide you want to switch 
to the Original Medicare Plan. 

You have the right to buy any Medigap policy that is sold in your 
state by any insurance company. You must tell the health plan that 
you want to leave (disenroll) and give them a date to end your 
coverage. This date must be before you have been in the plan for 
a year. You will have from 60 calendar days before your coverage 
ends until 63 calendar days after your coverage ends to apply for 
a new Medigap policy. 

Your rights under this situation may last for an extra 12 months if 
the plan you first joined leaves the Medicare Program or stops 
giving care in your area before you have been in the plan for one 
year, AND you immediately join another Medicare Advantage 
Plan or PACE. 



59 



ection 6: Medigap Rights and Protections 



Medigap protections (continued) 



SITUATION #5: You dropped a Medigap policy to join a 
Medicare Advantage Plan or PACE, or to switch to a 
Medicare SELECT policy, for the first time, you have been 
in the plan less than a year, and you want to switch back. 



You have the right to go back to the Medigap policy you had, if 
the same insurance company still sells it. You need to tell the 
Medicare Advantage Plan, Medicare SELECT, or PACE that 
you want to leave (disenroll) and give them a date to end your 
coverage. This date must be before you have been in the plan 
for a year. 

If your former Medigap policy isn't available, you have the 
right to buy a Medigap Plan A, B, C, F, K, or L that is sold in 
your state by any insurance company. You will have from 60 
calendar days before your coverage ends until 63 calendar days 
after your coverage ends to apply for a new Medigap policy. 

Your rights under this situation may last for an extra 12 months 
if the plan you first joined leaves the Medicare Program or 
stops giving care in your area before you have been in the plan 
for one year, AND you immediately join another Medicare 
Advantage Plan or PACE. 



SITUATION #6: Your Medigap insurance company goes 
bankrupt and you lose your coverage, or your Medigap 
policy coverage ends through no fault of your own. 



You have the right to buy a Medigap Plan A, B, C, or F that is 
sold in your state by any insurance company. You will have 63 
calendar days from the date your coverage ends to apply for a 
new Medigap policy. Because Medigap policies are guaranteed 
renewable, the only way you would lose coverage under a 
Medigap policy would generally be if the insurance company 
goes bankrupt. 



60 



Medigap protections (continued) 



SITUATION #7: You leave a Medicare Advantage Plan, or 
drop a Medigap policy because the company hasn't followed 
the rules, or it misled you. 

In this situation, you leave the health plan because it failed to 
meet its contract obligations to you. For example, the company 
isn't paying your claims, or it used untrue statements to 
convince you to buy the policy. Generally, to have this right, 
you must have filed a grievance with the health plan, 
Medicare, or the State Insurance Department (see pages 
85-86) and received a decision that the plan was at fault. 

You have the right to buy a Medigap Plan A, B, C, or F that is 
sold in your state by any insurance company. You must tell the 
plan that you want to leave (disenroll) and give them a date to 
end your coverage. You will have 63 calendar days from the 
date your coverage ends to apply for a new Medigap policy. 



61 



Medigap protections (continued) 



SITUATION #8: You have a Medigap policy that covers 
prescription drugs. You want to enroll in a new Medicare 
prescription drug plan and switch to another Medigap policy 
that doesn't have prescription drug coverage. 

If you enroll in a Medicare prescription drug plan between 
November 15, 2005 and May 15, 2006, you will be able to keep 
your Medigap policy, but the prescription drug coverage will be 
removed as of January 1, 2006. You also have the right to 
switch from the Medigap policy you have now and buy a 
Medigap Plan A, B, C, F (including the high-deductible Plan F), 
K, or L that is sold by your current Medigap insurance 
company. However, you are only guaranteed this right from the 
same insurance company. If you apply to a different insurance 
company they may be able to use medical underwriting. 

You must apply for your new Medigap policy within 63 calendar 
days after your Medicare prescription drug coverage starts. 

If you sign up for a Medicare prescription drug plan after 
May 15, 2006, you will no longer have the right to buy another 
Medigap policy from the same insurance company, unless your 
state has a law that requires it. 

Important: Starting January 1, 2006, no new Medigap policies 
with prescription drug coverage can be sold. 

If you have a Medigap policy that covers prescription drugs you 
will get a notice from your Medigap insurance company 
sometime between September 15, 2005 and November 15, 2005. 
This notice will describe your options for getting prescription 
drug coverage. Read the entire notice carefully and review your 
options before making any decisions. 

More information about Medicare prescription drug plans starts 
on page 38. 



62 






■wsrangniaiaETflffE 



p Rights and Protections 




Medigap protections (continued) 

Special note for people with Medicare under age 65 

If you are in a situation that gives you the right to 

• return to a Medigap policy you used to have, or 

• buy Medigap Plans A, B, C, or F, 

you must be allowed to return to the same type of Medigap policy 
you used to have, if it is still available from your old insurance 
company, or buy a Medigap Plan A, B, C, or F that is sold by any 
insurance company in your state to people under age 65. 

There is no Federal law that says insurance companies must sell 
Medigap policies to people under age 65. However, if an insurance 
company does sell these Medigap policies to anyone under age 65, 
they must sell one to you if you are in one of these situations (listed 
on pages 56-62). 

Note: If the Medigap policy you used to have included prescription 
drug coverage, you won't be able to get this coverage back. 

Where to get more information about 
Medigap protections 

• Call your State Health Insurance Assistance Program (see 
pages 85-86) to make sure that you qualify for these Medigap 
protections. They can also help you find the Medigap policy 
that is right for you. 

• Call your State Insurance Department (see pages 85-86) if you 
are denied Medigap coverage in any of these situations. 



63 



tfrr 




I used this section to 
learn about my Medigap 
rights and protections." 



64 



section 




Medigap 
Policies 
and 

Disability 
or ESRD 



This section has 

information about how 

Medigap policies work 

if you are disabled or 

have ESRD. 



Section 7: Medigap Policies and Disability or ESRD 



Medigap policies for people under age 65 and 
eligible for Medicare because of a disability or 
End-Stage Renal Disease (ESRD) 

You may have Medicare before age 65 due to 

• a disability, or 

• ESRD (permanent kidney failure requiring dialysis or a kidney 
transplant). 



Words in green 
are defined on 
pages 88-91. 



If you are a person with Medicare under age 65 and are disabled or 
have ESRD, you might not be able to buy the Medigap policy you want 
until you turn age 65. Federal law doesn't require insurance companies 
to sell Medigap policies to people under age 65. However, some states 
require Medigap insurance companies to sell you a Medigap policy, at 
certain times (during a limited Medigap open enrollment period), even 
if you are under age 65 (see pages 56-62). These states are listed 
below. If you have questions, you should call your State Health 
Insurance Assistance Program (see pages 85-86). 

At the time of printing this guide, the following states require insurance 
companies to offer at least one kind of Medigap policy to people with 
Medicare under age 65: 



California 

Colorado 

Connecticut 

Kansas 

Louisiana 

Maine 

Maryland 

Massachusetts 



Michigan 
Minnesota 
Mississippi 
Missouri 
New Hampshire 
New Jersey 
New York 
North Carolina 



Oklahoma 

Oregon 

Pennsylvania 

South Dakota 

Texas 

Vermont 

Washington 

Wisconsin 



Even if your state isn't on this list, some insurance companies may 
voluntarily sell Medigap policies to some people under age 65 (see 
pages 56-62). Whether or not your state requires insurance companies 
to sell to you, Medigap policies sold to people under age 65 may cost 
you more than policies sold to people over age 65. 

Remember, if you live in a state that has a Medigap open enrollment 
period for people under age 65, you will still get another Medigap open 
enrollment period when you turn age 65. You may have other choices of 
Medigap policies or be able to get a lower premium at that time. 



66 




iHajfi 



|[H[**:lir»l»JR 



ability or ESRD 



Medigap policies for people under age 65 and 
eligible for Medicare because of a disability or 
End-Stage Renal Disease (ESRD) (continued) 

Also, if you join a Medicare Advantage Plan and your coverage 
ends, you may have the right to buy a Medigap policy. If you have 
questions, you should call your State Health Insurance Assistance 
Program (see pages 85-86). 

Medigap policies for people age 65 or older 
and eligible for Medicare because of a 
disability or End-Stage Renal Disease (ESRD) 

The first six months after you turn age 65 and are enrolled in 
Medicare Part B is when you will be in your Medigap open 
enrollment period. It doesn't matter that you have had Medicare 
Part B before you turned age 65. During this time 

• you can buy any Medigap policy from any insurance 
company, and 

• insurance companies can't refuse to sell you a Medigap policy 
due to a disability or other health problem, or charge you a 
higher premium (based on health status) than they charge other 
people who are 65 years old. 

When you buy a Medigap policy during your Medigap open 
enrollment period, the insurance company must shorten the 
waiting period for pre-existing conditions by the amount of 
creditable coverage you have. If you had Medicare for more than 
six months before you turned 65 years old, you won't have a 
pre-existing condition waiting period because Medicare counts as 
creditable coverage. (See page 30 for more information about 
creditable coverage.) 




67 



Section 7: Medigap Policies and Disability or ESRD 




I wasn't sure if 
I could buy a 
Medigap 
policy, so I 
called my 
State Health 
Insurance 
Assistance 
Program. They 
were very 
helpful and 
answered all of 
my questions." 



Right to suspend a Medigap policy for 
people with Medicare who have a disability 

If you are under age 65, have Medicare, have a Medigap policy, 
and have employer group health plan coverage, you have a right to 
put your Medigap policy on hold ("suspend"). Your Medigap 
coverage will stop, and you don't have to pay the monthly 
premium while you are enrolled in your or your spouse's employer 
group health plan. You won't have to pay more when you start your 
Medigap policy again than you would otherwise have to pay if you 
had not suspended your policy. 

If, for any reason, you lose your employer group health plan 
coverage, you can get your Medigap policy back. Within 90 days 
of losing your employer group health plan coverage, you must 
notify your Medigap insurance company that you want your 
Medigap policy back. If your Medigap policy included 
prescription drug coverage, you can still get your Medigap 
policy back but without the prescription drug coverage (after 
January 1,2006). 

Your Medigap benefits and premiums will start again on the day 
your employer group health plan coverage stops. The Medigap 
policy must have the same benefits and premiums it would have 
had if you had never suspended your coverage. Your Medigap 
insurance company can't refuse to cover care for any pre-existing 
conditions (health problems) you have (see page 29). So, if you 
are disabled and working, you can enjoy the benefits of your 
employer's insurance while knowing that you will be able to get 
your Medigap policy back when you need it. 



68 



section 




Other Ways 
to Pay 
Health 
Care Costs 



r 
■ 



This section has 

helpful information 

about other ways 

to pay for your 

health care. 



8: Other Ways to 



Other kinds of insurance and ways to pay 
health care costs 

There are other kinds of health care coverage, besides a Medigap 
policy, that may pay some of your health care costs not covered by 
Medicare. The chart on pages 71-77 describes some of the 
following types of insurance and other ways to pay health care costs: 

Page(s) 

COBRA coverage „ 71-72 

Employee or retiree coverage from an employer or union 72 

Federally Qualified Health Centers (FQHCs) 72 

Home and Community-Based Service/Waiver programs 

(HCBS) 73 

Hospital indemnity insurance 73 

Long-term care insurance 73 

Medicaid 74-75 

Medicare-approved drug discount cards 75 

Medicare Savings Programs (help from your state) 76 

Military retiree benefits (TRICARE) 76 

PACE (Programs of All-inclusive Care 

for the Elderly) 76 

Prescription drug and other assistance programs 77 

Specified disease insurance 77 

State Children's Health Insurance Program (SCHIP) 77 

Veterans' benefits 77 



70 



Section 8: Other Ways to Pay Health Care Costs 




Types of insurance 
or other ways to pay 
health care costs... 



COBRA 

("Continuation 
Coverage" under the 
Consolidated 
Omnibus Budget 
Reconciliation Act) 
may give you and 
your dependents the 
right to keep your 
health care coverage 
temporarily if 

• you lose your job, 

• your working hours 
are reduced, 

• you leave your job 
voluntarily, or 

• your employer goes 
bankrupt. 

COBRA may also 

help your spouse 
temporarily keep 
health care coverage 
if you die, or you get 
divorced. 



A quick look at how it works. 



If you are covered under an employer or retiree health plan, and you 
lose your coverage for one of the reasons listed in the left-hand 
column, COBRA allows you to keep your coverage for a while longer. 
However, if you also have Medicare you need to know about how 
COBRA may affect some of your choices under Medicare 
and Medigap. 

When you have COBRA coverage before Medicare starts 

If you already have COBRA when you enroll in Medicare, your 
employer may stop your COBRA coverage entirely, or change the 
length of time your spouse can have coverage under COBRA. 

However, if you have the opportunity to keep your COBRA for a 
while, you might think it's better to keep the COBRA and not start 
paying premiums under Medicare Part B. Here's what you need 
to consider: 

• When you become eligible for Medicare at age 65 you have an 
"Initial Enrollment Period" for Part B. Some people who are 
still working can wait and have a "Special Enrollment Period" 
after they stop working. However, if you or your spouse aren't 
working, you will have to pay more for Part B if you join after 
your Initial Enrollment Period. Therefore, you need to think 
about how long you will be able to keep your COBRA, and 
whether you would be better off if you sign up for Part B. 

• Enrolling in Part B, regardless of when you enroll after you are 
age 65, starts your six-month Medigap open enrollment period. 
Once this period starts, it can't be changed. If you stay on 
COBRA, and enroll in Part B, but decide to wait until after your 
open enrollment period to buy a Medigap policy, you may have 
trouble buying a Medigap policy if you have health problems. 

• Once your open enrollment period ends, the only way you have 
guaranteed rights to buy a Medigap policy is if you have 
"Medigap protections." (See Medigap protections, Situation #2 
on page 57.) 

Whatever you decide to do, you need to keep in mind the timeframes 
for getting each type of coverage: 

• For COBRA you have 60 days to sign up for the coverage, 
beginning either the day you lose your employer coverage, or the 
day you get a notice that you have COBRA rights, whichever 
comes later. 



71 




Types of insurance 
or other ways to pay 
health care costs... 


A quick look at how it works... 


COBRA (continued) 


Whatever you decide to do, you need to keep in mind the timeframes 
for getting each type of coverage: (continued) 

• Your Initial Enrollment Period for Part B starts three months 
before you turn age 65. 

• Your Medigap open enrollment period is the six-month period 
that starts on the first day of the month in which you are both 
age 65 or older and enrolled in Medicare Part B. During this 
period you have the right to buy any Medigap policy. 

• For Medigap protections you have 63 days to sign up after you 
find out that your employer coverage has ended. 

• If you decide you want to join a Medicare health plan instead 
of the Original Medicare Plan, there may be limits on the times 
you can enroll. 


Employee or retiree 
coverage from an 
employer or union may 
help 

employees or spouses 
who had health care 
coverage from a current 
or previous employer or 
union. 


In some cases, you or your spouse might be able to get your health 
care coverage from an employer or union based on your or your 
spouse's current employment. This is called "employee coverage." 

Some employers or unions might let you or your spouse continue 
your health care coverage after the employment ends. This is called 
"retiree coverage." 

If you have this type of coverage from an employer or union, they 
may change the benefits or premiums, and may also be able to 
cancel the coverage if they choose. 

If you or your spouse are working and have group health coverage 
based on current or active employment there are special things to 
think about with Part B and Medigap policies. See the information 
about Medigap open enrollment period on pages 26-28. 

Employee and retiree coverage and Medigap 

If you have employee or retiree coverage and it ends, you may have 
the right to buy a Medigap policy. You may get a notice or claim 
denial letting you know that your health care coverage is ending. 
You have 63 calendar days from the date your coverage ends or 
from the notice or claim denial to apply for a Medigap policy (see 
Medigap protections, Situation #2 on page 57). 


Federally Qualified 
Health Centers 
(FQHCs) may help 

people who live near a 
FQHC. 


FQHCs are special health centers, usually located in urban or rural 
areas, that can give routine health care at a lower cost. Some 
FQHCs are Community Health Centers, Tribal FQHC Clinics, 
Certified Rural Health Clinics, Migrant Health Centers, and Health 
Care for the Homeless Programs. 



72 






Section 8: Other Ways to Pay Health Care Costs 



Types of insurance 
or other ways to pay 
health care costs... 


A quick look at how it works... 


Home and 
Community-Based 
ServiceAVaiver 
programs (HCBS) 
may help 
certain elderly and 
disabled individuals. 


HCBS programs are available to some people with Medicaid. 
They offer services and programs that help you get care in your 
home and community. Some examples of this care include 
homemaker services, personal care, adult day care, meals, and 
transportation. This program allows you to stay more independent. 


Hospital indemnity 
insurance may help 

pay for hospital stays 
up to a certain number 
of days. 


This kind of insurance pays a set amount of money for each day 
of a hospital stay. You won't need this insurance if your health 
insurance coverage or Medigap policy already pays for this type 
of care. This insurance doesn't fill gaps in your Medicare 
coverage. It usually pays in addition to your health insurance. 


Long-term care 
insurance may help 

pay for your health or 
personal care needs 
and activities of daily 
living, such as bathing, 
dressing, using the 
bathroom, and eating. 


Long-term care insurance is sold by private insurance companies 
and usually covers medical care and non-medical care. Make 
sure you choose the long-term care insurance policy that best 
meets your needs. 

For information about long-term care insurance, get a copy of 
"A Shopper's Guide to Long-Term Care Insurance" from either 
your State Insurance Department (see pages 85-86) or the 
National Association of Insurance Commissioners, 
2301 McGee Street, Suite 800, Kansas City, MO 64108-3600. 
Or, call your State Health Insurance Assistance Program 
(see pages 85-86). 




73 



Section 8: Other Ways to Pay Health Care Costs 



Types of insurance 
or other ways to pay 
health care costs... 



A quick look at how it works... 



Medicaid may help 

people with limited 
incomes and 
resources. 



Medicaid helps pay your medical costs. Since Medicaid is a joint 
Federal and state program, coverage varies from state to state. 

People with Medicaid may get coverage for things like nursing 
home care and home care that aren't covered by Medicare. 

Starting in 2006, Medicare will cover outpatient prescription 
drugs instead of Medicaid. Medicare will send you information 
about these changes in 2005. 

Medicaid and Medigap 

If you have a Medigap policy and then get Medicaid, there are a 
few things you should know: 

• You can put your Medigap policy on hold ("suspend") within 
90 days of getting Medicaid. 

• You won't have to pay your Medigap policy premiums while 
it is suspended. 

• Your Medigap policy won't pay benefits while the Medigap 
policy is suspended. 

• You can suspend a Medigap policy for up to two years. 

• At the end of the suspension, you can restart the Medigap 
policy without new medical underwriting or pre-existing 
condition waiting periods. 

• Starting January 1, 2006, if you suspend your Medigap policy 
and it includes prescription drug coverage, you can still get the 
Medigap policy back but without the prescription drug coverage. 

To help you with making a decision about suspending a Medigap 
policy, call your State Medical Assistance Office. To get their 
telephone number, call 1-800-MEDICARE (1-800-633-4227). 
For questions about suspending a Medigap policy, call your 
insurance company. 



74 









Section 8: Other Ways to Pay Health Care Co: 






Types of insurance 
or other ways to pay 
health care costs... 


A quick look at how it works... 


Medicaid (continued) 


If you already have health insurance coverage through your state 
Medicaid Program, an insurance company can sell you a Medigap 
policy only in certain situations: 

• The insurance company can legally sell you any Medigap policy if 
Medicaid pays your Medigap policy premium or if Medicaid only 
pays your Medicare Part B premium. 

• The insurance company can legally sell you Medigap Plans H, I, 
or J if Medicaid only pays your Medicare premiums, deductibles, 
or coinsurance. (This only applies to Medigap policies sold 
between now and January 1, 2006.) 

In any other situation, it is illegal for an insurance company to sell 
you a Medigap policy if you are getting any Medicaid benefits. 


Medicare-approved 
drug discount cards 
may help 

people save money on 
prescription drugs. 


Medicare contracts with private companies to offer drug discount 
cards. This is a temporary program to help with your prescription 
costs until Medicare prescription drug plans start in 2006. You can 
enroll in this program through November 30, 2005. 
Medicare-approved drug discount cards are good until 
May 15, 2006, or until you enroll in a Medicare prescription drug 
plan, whichever is first. You might be able to save on prescription 
drugs with a Medicare-approved drug discount card. For more 
information about Medicare-approved drug discount cards, visit 
www.medicare.gov on the web. Select "Search Tools" at the top of 
the page. Or, call 1-800-MEDICARE (1-800-633-4227). TTY 
users should call 1-877-486-2048. 

Drug discount cards and Medigap Policies 

You might already have a drug discount card with your Medigap 
policy. If the drug discount card you have with your Medigap 
policy isn't a Medicare-approved drug discount card, you can 
also get a Medicare-approved drug discount card. 



75 



Section 8: Other Ways to Pay Health Care Costs 



Types of insurance 
or other ways to pay 
health care costs... 


A quick look at how it works... 




Medicare Savings 
Programs (help from 
your state as part of 
the State Medical 
Assistance Program) 
may help 

people with limited 
income and resources. 


These programs can help pay your Medicare premiums and, in 
some cases, may also pay Medicare deductibles and coinsurance. 
To be eligible for this program, you must meet certain 
requirements. 

These programs may not be available in Guam, Puerto Rico, the 
Virgin Islands, the Northern Mariana Islands, and 
American Samoa. 

To find out if these programs are available in your area or for 
more information, call your State Medical Assistance Office. 
To get their telephone number, call 1-800-MEDICARE 
(1-800-633-4227). Since the names of these programs may vary 
by state, ask for information on Medicare Savings Programs. 




Military retiree 
benefits (TRICARE) 
may help 

active duty and retired 
uniformed services 
members and their 
families. 


TRICARE is a health care program that offers medical coverage 
to eligible members. The TRICARE Program includes TRICARE 
Prime, TRICARE Extra, TRICARE Standard, and TRICARE for 
Life (TFL). 

If eligible, you get all Medicare-covered benefits under the 
Original Medicare Plan, plus all TFL-covered benefits. 

For more information about the TRICARE Programs, call 
1-800-538-9552 or visit www.tricare.osd.mil on the web. 


PACE (Programs of 
All-inclusive Care for 
the Elderly) may help 

frail people who live in 
the service area of 
PACE. 


PACE combines medical, social, and long-term care services for 
frail people. PACE might be a better choice for you than getting 
your care through a nursing home. PACE is available only in states 
that have chosen to offer it under Medicaid. If you live in a state 
that offers PACE, and you have Medicare and are eligible for 
PACE, you can choose to get your Medicare benefits through this 
program. 

To find out if you are eligible and if there is a PACE site near you, 
or for more information, call your State Medical Assistance 
Office. To get their telephone number call 1-800-MEDICARE 
(1-800-633-4227). TTY users should call 1-877-486-2048. Or, 
visit www.medicare.gov on the web. 





76 



Section 8: Other Ways to Pay Health Care Costs 




Types of insurance 
or other ways to pay 
health care costs... 



A quick look at how it works... 



Prescription drug 
and other assistance 
programs may help 

people get discounted 
or free prescription 
drugs. 



Some states offer programs that either offer lower cost or free 
prescription drugs. They may also offer other assistance programs 
to help pay for your other health care costs. To be eligible for 
these programs, you must meet certain requirements. For more 
information, visit www.medicare.gov on the web. Select "Search 
Tools" at the top of the page. Or, call 1-800-MEDICARE 
(1-800-633-4227). TTY users should call 1-877-486-2048. 

Prescription drugs and Medigap 

If you are thinking about signing up for your state's prescription 
drug assistance program and you haven't yet bought a Medigap 
policy, get your Medigap policy before you apply for 
prescription drug assistance. After you get the prescription drug 
assistance you might not be able to buy a Medigap policy. 



Specified disease 
insurance may help 

people with a certain 
type of disease. 



Specified disease insurance pays benefits for a single disease, such 
as cancer, or for a group of diseases. You usually have to buy this 
insurance before you are diagnosed or treated for the 
specified disease. 

You won't need this insurance if your health insurance coverage or 
Medigap policy already pays for this type of care. This insurance 
doesn't fill gaps in your Medicare coverage. It usually pays in 
addition to your health insurance. 



State Children's 
Health Insurance 
Program (SCHIP) 
may help 

uninsured children 
underage 19. 



Some states offer free or low-cost health insurance to uninsured 
children whose families don't qualify for Medicaid. For more 
information about your state's program, visit 
www.cms.hhs.gov/schip/ on the web. 



Veterans' benefits 
may help 

people who have had 
any military service 
or are veterans. 



The U.S. Department of Veterans Affairs offers health care 
benefits and other types of benefits and services to eligible 
members. For more information about VA benefits and services, 
call the U.S. Department of Veterans Affairs at 1-800-827-1000. 



77 



HTffl 



riJ^ 



Hh 




^i 







"Be sure to compare Medigap 
policies and your other 
Medicare health care options. 
It could save you money." 



78 



section 





Massachusetts, 
Minnesota, and 
Wisconsin 
Medigap 
Plans 



Different types of 

standardized Medigap 

plans are sold in these 

three states. For 

standardized Medigap 

plans sold in other 

states, seepages \9 A 

and 2 1 , 



Section 9: Massachusetts, Minnesota, Wisconsin Medigap Plans 



Massachusetts - Chart Of Standardized Medigap Plans 

Basic benefits included in all plans: 

• Inpatient Hospital Care: Covers the Medicare Part A coinsurance and the cost of 
365 extra days of hospital care during your lifetime after Medicare coverage ends. 

• Medical Costs: Covers the Medicare Part B coinsurance (generally 20% of the 
Medicare-approved payment amount). 

• Blood: Covers the first three pints of blood each year. 



Medigap Benefits 


Core 
Plan 


Core Plan 
with Rider* 


Supplement 
1 Plan 


Supplement 
2 Plan 


Basic Benefits 


/ 


/ 


/ 


/ 


Medicare Part A: Inpatient 
Hospital Deductible 






/ 


/ 


Medicare Part A: Skilled-Nursing 
Facility Coinsurance 






/ 


/ 


Medicare Part B: Deductible 






/ 


/ 


Foreign Travel 
Emergency 




/ 


/ 


/ 


Inpatient Days in Mental 
Health Hospitals 


60 days per 
calendar year 




120 days per 
benefit year 


120 days per 
benefit year 


Prescription Drugs** 
($35 deductible each calendar 
quarter, then 100% coverage for 
generic drugs and 80% coverage 
for brand name drugs) 




(Limited) 




/ 

(Limited) 


State-Mandated Benefits 
(Annual Pap tests and 
mammograms. Check your plan 
for other state-mandated benefits.) 


/ 


- 


/ 


/ 


* This plan, offered by Blue Cross and E 
services: routine vision services, routine < 
programs. Contact plan for details. For n 
(see pages 85-86) or visit www.medicar 


Hue Shield of Ma 
iental services, roi 
lore information c 
e.gov on the web. 


ssachusetts, also 
iitine hearing sen 
m these policies, 
Select "Search " 


provides coverage 
dees, fitness progra 
call your State Insi 
^ools" at the top of 


? or the following 
ms, and weight loss 
irance Department 
the page. 



80 



** Prescription drug coverage may not be sold after January 1, 2006. 

Note: The check marks in this chart mean the benefit is covered under that plan. 



isl A SHJgB iTBf 3 1 Ml A 1 1 iWAf A kWH \AM iH 1 .1 A P3i 




ection 



Minnesota - Chart Of Standardized Medigap Plans 

Basic benefits included in all plans: 

• Inpatient Hospital Care: Covers the Medicare Part A coinsurance. 

• Medical Costs: Covers the Medicare Part B coinsurance (generally 
20% of the Medicare-approved payment amount). 

• Blood: Covers the first three pints of blood each year. 



Medigap Benefits 


Basic Plan 


Extended 
Basic Plan 


Basic Benefits 


/ 


/ 


Medicare Part A: Inpatient 
Hospital Deductible 




/ 


Medicare Part A: Skilled- 
Nursing Facility Coinsurance 


/ 


/ 


Medicare Part B: Deductible 




/ 


Foreign Travel Emergency 


80% 


80%* 


Outpatient Mental Health 


50% 


50% 


Usual and Customary Fees 




80%* 


Preventive Care 


/ 


/ 


Prescription Drugs** 




80% 


At-home Recovery 




/ 


Physical Therapy 


20% 


20% 


Coverage while in a 
Foreign Country 




80%* 


State-Mandated Benefits 
(Diabetic equipment 
and supplies, routine cancer 
screening, reconstructive surgery, 
and immunizations.) 


/ 


/ 



Optional Riders 



• Medicare Part A: 
Inpatient Hospital 
Deductible 

• Medicare Part B: 
Deductible 

• Usual and Customary 
Fees 

• Preventive Care 

• Prescription Drugs** 

• At-home recovery 

Insurance companies 
are allowed to offer 
six additional riders 
that can be added to a 
Basic plan. You may 
choose any one or all 
of the riders to design 
a Medigap plan that 
meets your needs. 



ijj >ji 



Prescription drug 
coverage may not be 
sold after January 1 , 
2006. 



* The policy pays 100% after you spend $1000 of out-of-pocket expenses for a calendar year. 
Note: The check marks in this chart mean the benefit is covered under that plan. 81 




nnphiTTiiPffiiHIi'illiliW^IVIHtiiHIili'iH' 




Wisconsin - Chart Of Standardized Medigap Plans 



Basic benefits included in all plans: 

• Inpatient Hospital Care: Covers the Medicare Part A coinsurance. 

• Medical Costs: Covers the Medicare Part B coinsurance (generally 
20% of the Medicare-approved payment amount). 

• Blood: Covers the first three pints of blood each year. 



Medigap Benefits 


Basic Plan 


Basic Benefits 


/ 


Medicare Part A: 
Skilled-Nursing Facility 
Coinsurance 


/ 


Inpatient Mental 
Health Coverage 


175 days per lifetime in 
addition to Medicare 


Home Health Care 


40 visits in addition to 
those paid by Medicare 


Medicare Part B: 
Coinsurance 


/ 


Outpatient Mental Health 


/ 


Prescription Drugs * 
(after a deductible of 
$6,250, pays 80%) 


/ 



Optional Riders 



• Medicare Part A Deductible 

• Additional Home Health Care 
(365 visits including those 
paid by Medicare) 

• Medicare Part B Deductible 

• Medicare Part B Excess 
Charges 

• Outpatient Prescription Drugs* 

• Foreign Travel 

Insurance companies are 
allowed to offer additional riders 
to a Medigap plan. 



* Prescription drug coverage may not be sold after January 1, 2006. 

For more information on these policies, call your State Insurance Department (see 
pages 85-86) or visit www.medicare.gov on the web. Select "Search Tools" at the 
top of the page. 

Note: The check marks in this chart mean the benefit is covered under that plan. 



82 



section 




For More 
Information 



Use this section 

to learn where to get 

more information. 



Words in green 
are defined on 
pages 88-91. 



On pages 85-86, you will find telephone numbers for your State 
Health Insurance Assistance Program and State Insurance 
Department. These telephone numbers were correct at the time of 
printing. Telephone numbers sometimes change. You can find the 
most up-to-date telephone numbers by visiting www.medicare.gov 
on the web. Select "Search Tools" at the top of the page. Or, call 
1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. 

Where to get more information 

• Call your State Health Insurance Assistance Program (see 
pages 85-86) for help with 

■ buying a Medigap policy or long-term care 
insurance, 

■ choosing a Medicare prescription drug plan, 

■ dealing with payment denials or appeals, 

■ Medicare rights and protections, 

■ choosing a Medicare health plan, 

■ deciding whether to suspend your Medigap policy, or 

■ questions about Medicare bills. 

• Call your State Insurance Department (see pages 85-86) if 
you have questions about the Medigap policies sold in your 
area or any insurance-related problems. 

Where to call with Medicare questions 

If you have questions about Medicare, call 1-800-MEDICARE 
(1-800-633-4227). Customer service representatives are available 
24 hours a day, seven days a week. TTY users should call 
1-877-486-2048. 



84 



State 


State Health Insurance 
Assistance Program 


State Insurance 
Department 


Alabama 


(800) 243-5463 


(800) 433-3966 


Alaska 


(800) 478-6065 


(800) 467-8725 


American Samoa 


(888) 875-9229 


(684)633-4116 


Arizona 


(800) 432-4040 


(800) 325-2548 


Arkansas 


(800) 224-6330 


(800) 282-9134 


California 


(800) 434-0222 


(800) 927-4357 


Colorado 


(800) 243-5463 


(800) 930-3745 


Connecticut 


(800) 994-9422 


(800) 203-3447 


Delaware 


(800) 336-9500 


(800)282-8611 


Florida 


(800) 963-5337 


(800) 342-2762 


Georgia 


(800) 669-8387 


(800) 656-2298 


Guam 


(888) 875-9229 


(671)475-1817 


Hawaii 


(888) 875-9229 


(808) 586-2790 


Idaho 


(800) 247-4422 


(800) 721-3272 


Illinois 


(800) 548-9034 


(866) 445-5364 


Indiana 


(800) 452-4800 


(800)622-4461 


Iowa 


(800)351-4664 


(800)351-4664 


Kansas 


(800) 860-5260 


(800) 432-2484 


Kentucky 


(877) 293-7447 


(800) 595-6053 


Louisiana 


(800) 259-5301 


(800) 259-5300 


Maine 


(800) 750-5353 


(800) 300-5000 


Maryland 


(800) 243-3425 


(800)492-6116 


Massachusetts 


(800) 243-4636 


(617)521-7794 


Michigan 


(800) 803-7174 


(877) 999-6442 


Minnesota 


(800) 333-2433 


(800) 657-3602 


Mississippi 


(800) 948-3090 


(800) 562-2957 


Missouri 


(800) 390-3330 


(800) 726-7390 


Montana 


(800)551-3191 


(800)332-6148 



85 



86 



Section 10: For More Information 


State 


State Health Insurance 
Assistance Program 


State Insurance 
Department 


Nebraska 


(800)234-7119 


(800)234-7119 


Nevada 


(800) 307-4444 


(800) 992-0900 


New Hampshire 


(800) 852-3388 


(800) 852-3416 


New Jersey 


(800) 792-8820 


(800) 446-7467 


New Mexico 


(800) 432-2080 


(800) 947-4722 


New York 


(800)333-4114 


(800) 342-3736 


North Carolina 


(800) 443-9354 


(800) 546-5664 


North Dakota 


(800) 247-0560 


(800) 247-0560 


Northern Mariana 
Islands 


(888) 875-9229 


(670)664-3017 


Ohio 


(800)686-1578 


(800) 686-1526 


Oklahoma 


(800) 763-2828 


(800) 522-0071 


Oregon 


(800) 722-4134 


(888) 877-4894 


Pennsylvania 


(800) 783-7067 


(877) 881-6388 


Puerto Rico 


(877) 725-4300 


(888) 722-8686 


Rhode Island 


(401)462-0508 


(401)222-2223 


South Carolina 


(800) 868-9095 


(800) 768-3467 


South Dakota 


(800) 536-8197 


(877)310-6560 


Tennessee 


(877) 801-0044 


(800) 342-4029 


Texas 


(800) 252-9240 


(800) 252-3439 


Utah 


(800) 541-7735 


(866) 350-6242 


Vermont 


(800)642-5119 


(800)631-7788 


Virgin Islands 


(340)776-8311 


(340) 773-6449 


Virginia 


(800) 552-3402 


(877)310-6560 


Washington 


(800) 562-6900 


(800) 562-6900 


Washington D.C. 


(202) 739-0668 


(202) 727-8000 


West Virginia 


(877) 987-4463 


(888) 879-9842 


Wisconsin 


(800)242-1060 


(800)236-8517 


Wyoming 


(800)856-4398 


(800) 438-5768 



section 





Words 
to Know 




Section 11: Words to Know 



Assignment — In the Original Medicare Plan, 
this means a doctor agrees to accept the 
Medicare-approved amount as full payment. 
If you are in the Original Medicare Plan, it 
can save you money if your doctor accepts 
assignment. You still pay your share of the 
cost of the doctor's visit. 

Benefit Period — The way that Medicare 
measures your use of hospital and skilled 
nursing facility (SNF) services. A benefit 
period begins the day you go to a hospital or 
skilled nursing facility. The benefit period ends 
when you haven't received any hospital care 
(or skilled care in a SNF) for 60 days in a row. 
If you go into the hospital or a SNF after one 
benefit period has ended, a new benefit period 
begins. If you are in the Original Medicare 
Plan, you must pay the inpatient hospital 
deductible for each benefit period. There is 
no limit to the number of benefit periods you 
can have. 

Coinsurance — The percent of the Medicare- 
approved amount that you have to pay after 
you pay the deductible for Part A and/or 
Part B. In the Original Medicare Plan, the 
coinsurance payment is a percentage of the 
approved amount for the service (like 20%). 

Copayment — In some Medicare health plans, 
the amount that you pay for each medical 
service, like a doctor's visit. A copayment is 
usually a set amount you pay for a service. 
For example, this could be $10 or $20 for a 
doctor's visit. Copayments are also used for 
some hospital outpatient services in the 
Original Medicare Plan. 

Creditable Coverage (Medigap) — Certain 
kinds of previous health insurance coverage 
that can be used to shorten a pre-existing 
condition waiting period. (See pre-existing 
conditions.) 



Deductible — The amount you must pay for 
health care or prescriptions, before Medicare 
or your prescription drug plan begins to pay. 
For example, either for each benefit period for 
Part A, or each year for Part B. These 
amounts can change every year. 

End-Stage Renal Disease 

(ESRD) — Permanent kidney failure that 
requires dialysis or a kidney transplant. 

Excess Charges — If you are in the Original 
Medicare Plan, this is the difference between a 
doctor's or other health care provider's actual 
charge (which may be limited by Medicare or 
the state) and the Medicare-approved payment 
amount. 

Guaranteed Issue Rights (also called 
"Medigap Protections") — Rights you have in 
certain situations when insurance companies 
are required by law to sell or offer you a 
Medigap policy. In these situations, an 
insurance company can't deny you insurance 
coverage or place conditions on a policy, must 
cover you for all pre-existing conditions, and 
can't charge you more for a policy because of 
past or present health problems. 

Guaranteed Renewable — A right you have 
that requires your insurance company to 
automatically renew or continue your 
Medigap policy, unless you make untrue 
statements to the insurance company, commit 
fraud or don't pay your premiums. 

Hospice Care — A special way of caring for 
people who are terminally ill, and for their 
family. This care includes physical care and 
counseling. Hospice care is covered under 
Medicare Part A (Hospital Insurance). 



88 






ection 



now 



Lifetime Reserve Days — In the Original 
Medicare Plan, there are 60 days that 
Medicare will pay for when you are in a 
hospital more than 90 days during a benefit 
period. These 60 reserve days can be used 
only once during your lifetime. For each 
lifetime reserve day. Medicare pays all 
covered costs except for a daily coinsurance 
($456 in 2005). 

Long-term Care — A variety of services that 
help people with health or personal needs and 
activities of daily living over a long period of 
time. Long-term care can be provided at 
home, in the community, or in various types 
of facilities, including nursing homes and 
assisted living facilities. Most long-term care 
is custodial care. Medicare doesn't pay for 
this type of care if this is the only kind of care 
you need. 

Managed Care Plan — A type of Medicare 
Advantage Plan that is available in some areas 
of the country. In most managed care plans, 
you can only go to doctors, specialists, or 
hospitals on the plan's list. Plans must cover 
all Medicare Part A and Part B health care. 
Some managed care plans cover extras, like 
prescription drugs. Your costs may be lower 
than in the Original Medicare Plan. 

Medicaid — A joint Federal and state program 
that helps with medical costs for some people 
with limited incomes and resources. Medicaid 
Programs vary from state to state, but most 
health care costs are covered if you qualify for 
both Medicare and Medicaid. 

Medical Underwriting — The process that an 
insurance company uses to decide, based on 
your medical history, whether or not to take 
your application for insurance, whether or not 
to add a waiting period for pre-existing 
conditions (if your state law allows it), and 
how much to charge you for that insurance. 



Medically Necessary — Services or supplies 
that 

• are proper and needed for the diagnosis 
or treatment of your medical condition; 

• are provided for the diagnosis, direct 
care, and treatment of your medical 
condition; 

• meet the standards of good medical 
practice in the local area; and 

• aren't mainly for the convenience of you 
or your doctor. 

Medicare Advantage Plan — A Medicare 
Program that gives you more choices among 
health plans. Everyone who has Medicare 
Parts A and B is eligible, except those who 
have End-Stage Renal Disease (unless certain 
exceptions apply). 

Medicare-approved Amount — In the 

Original Medicare Plan, this is the Medicare 
payment amount for an item or service. This 
is the amount a doctor or supplier is paid by 
Medicare and you for a service or supply. It 
may be less than the actual amount charged by 
a doctor or supplier. The approved amount is 
sometimes called the "Approved Charge." 

Medicare Prescription Drug 
Plan — Beginning January 1 , 2006, Medicare 
will provide prescription drug coverage 
through insurance companies and private 
companies. These companies will offer 
different Medicare prescription drug plans 
with different covered prescriptions and costs. 
Like other insurance, if you join a Medicare 
prescription drug plan you will pay a monthly 
premium, a yearly deductible, and a share of 
the cost of your prescriptions. You can sign up 
for one of these plans starting November 15. 
2005. Note: These plans are different than 
Medigap policies that offer prescription drug 
coverage (see "Medigap prescription drug 
coverage"). 89 



Section 1 1 : Words to Know 



Medicare SELECT— A type of Medigap 
policy that may require you to use hospitals 
and, in some cases, doctors within its network 
to be eligible for full benefits. 

Medigap Policy — A Medicare supplement 
insurance policy sold by private insurance 
companies to fill "gaps" in Original Medicare 
Plan coverage. There are 12 standardized 
plans labeled Plan A through Plan L, except in 
Massachusetts, Minnesota, and Wisconsin. 
These states have different standardized plans. 
Medigap policies only work with the Original 
Medicare Plan. 

Open Enrollment Period — A one-time-only 
six month period when you can buy any 
Medigap policy you want that is sold in your 
state. It starts in the first month that you are 
covered under Medicare Part B and you are 
age 65 or older. During this period, you can't 
be denied coverage or charged more due to 
past or present health problems. 

Original Medicare Plan — A fee-for-service 
health plan that lets you go to any doctor, 
hospital, or other health care supplier who 
accepts Medicare and is accepting new 
Medicare patients. You must pay the 
deductible. Medicare pays its share of the 
Medicare-approved amount, and you pay your 
share (coinsurance). In some cases you may 
be charged more than the Medicare-approved 
amount. The Original Medicare Plan has 
Part A (Hospital Insurance) and Part B 
(Medical Insurance). 

Pre-existing Condition — A health problem 
you had before the date that a new insurance 
policy starts. 



Preferred Provider Organization (PPO) 
Plan — A type of Medicare Advantage Plan in 
which you use doctors, hospitals, and 
providers that belong to the network. You can 
use doctors, hospitals, and providers outside 
of the network for an additional cost. 

Premium — The periodic payment to 
Medicare, an insurance company, or a health 
care plan for health care coverage. 

Private Fee-for-Service (PFFS) Plan — A 

type of Medicare Advantage Plan in which 
you may go to any Medicare-approved doctor 
or hospital that accepts the plan's payment. 
The insurance plan, rather than the Medicare 
program, decides how much it will pay and 
what you pay for the services you get. You 
may pay more for Medicare-covered benefits. 
You may have extra benefits the Original 
Medicare Plan doesn't cover. 

Programs of All-inclusive Care for the 
Elderly (PACE)— PACE combines medical, 
social, and long-term care services for frail 
people. PACE is available only in states that 
have chosen to offer it under Medicaid. To be 
eligible, you must 

• be 55 years old or older, 

• live in the service area of the PACE 
program, 

• be certified as eligible for nursing home 
care by the appropriate state agency, and 

• be able to live safely in the community. 

The goal of PACE is to help people stay 
independent and living in their community as 
long as possible, while getting the 
high-quality care they need. 



90 



Skilled Nursing Facility Care — A level of 
care that requires the daily involvement of 
skilled nursing or rehabilitation staff and can't 
be done on an outpatient basis. Examples of 
skilled nursing care include getting 
intravenous injections and physical therapy. 
A need for custodial care, such as help with 
bathing and dressing, can't, in itself, qualify 
you for Medicare coverage in a skilled nursing 
facility. However, if you qualify for skilled 
nursing or rehabilitation care, Medicare covers 
all of your care needs in the facility. 

Skilled Nursing Facility — A nursing facility 
with the staff and equipment to give skilled 
nursing care and/or skilled rehabilitation 
services and other related health services. 

Special Needs Plan — A type of Medicare 
Advantage Plan that provides more focused 
health care for some people. These plans give 
you all your Medicare health care as well as 
more focused care to manage a disease or 
condition such as congestive heart failure, 
diabetes, or End-Stage Renal Disease. 



State Health Insurance Assistance 
Program — A state program that gets money 
from the Federal Government to give free 
local health insurance counseling to people 
with Medicare. 

State Insurance Department — A state 
agency that regulates insurance and can 
provide information about Medigap policies 
and any insurance-related problems. 

State Medical Assistance Office — A state 
agency that is in charge of the state's 
Medicaid program and can give information 
about programs that help pay medical bills for 
people with low incomes. Also provides help 
with prescription drug coverage. 



91 



tfr§ 




"I keep this book on my 
shelf so I know where to 
find it if I have a question. 



92 



section 




List of 
Topics 



This section 

is an alphabetical list 

of specific topics 

discussed in this Guide, 

with page numbers. 



ection 12: List of Topics 



TIP: Use the "Table of Contents" on pages 1-2 to help you find 
the sections you want to read. 



Assignment 15, 34, 88 

At-Home Recovery 20, 47, 81 

Attained-Age-Rated Policies 22, 23 

B 

Basic Benefits 

Plans A through J 18, 43 

Plans K and L 19, 44, 45 

Basic Drug Benefit (Plans H and I) 20 

Benefit Period 15, 48, 88 

Blood 15, 18, 19,43,45,80-82 

C 

Cardiovascular Screening 4 

Changing (Switching) Medigap Policies 32 

Coinsurance 9, 18-21, 44, 46, 48, 75, 76, 80-82, 88 

Consolidated Omnibus Budget Reconciliation Act (COBRA).... 57, 71, 72 

Copayment 9, 15, 18, 19, 43, 44, 88 

Cost/Pricing Policies 22, 23 

Creditable Coverage (Medigap) 26, 30, 88 

D 

Deductible 9, 15, 18-21, 24, 43, 46-48, 75, 76, 80-82, 88 

Delaying Part B Enrollment 28 

Diabetes Screening 4, 47 

Disability 65-68 

E 

Employee Coverage 30, 72 

Employer Group Health Plan 55, 57, 68, 72 

End-Stage Renal Disease (ESRD) 16, 26, 66, 67, 88 

Excess Charges 15, 20, 46, 82, 88 

Extra Benefits 

Plans B through J 20, 46, 47 

Plans K and L 21, 48 

F 

Federally Qualified Health Centers 72 

Finding Reliable Insurance Companies 36 

Foreign Travel Emergency 20, 24, 46, 80-82 



94 



Section 12: List of Topics 



General Enrollment Period (Part B) 28 

Guaranteed Issue Rights 29, 54-62, 88 

Guaranteed Renewable 13, 33, 88 

H 

High-Deductible Option , 24 

Home and Community-Based Service/Waiver Programs (HCBS) 73 

Hospice Care 19, 45, 88 

Hospital Indemnity Insurance 30 

I 

Initial Enrollment Period 28 

Inspector General's Office 35 

Issue-Age-Rated Policies 22, 23 

L 

Lifetime Reserve Days 43, 89 

Long-Term Care (Insurance) 30, 73 

M 

Medicaid 13, 14, 30, 35, 74, 75, 77, 89 

Medical Underwriting 24, 27, 74, 89 

Medically Necessary 8, 89 

Medicare Advantage Plan 9, 10, 13, 14, 39, 55, 56, 58-61, 67, 89 

Medicare-Approved Amount 15, 43-47, 89 

Medicare-Approved Drug Discount Card 75 

Medicare Managed Care Plan 9, 89 

Medicare Part A (Hospital Insurance) 8-10, 13, 17-20, 26, 30 

43, 44, 46, 80-82 
Medicare Part B (Medical Insurance) 8-10, 13-20, 26, 28, 30, 43 

44, 46, 47, 80-82 

Medicare Preferred Provider Organization Plan 9, 90 

Medicare Prescription Drug Plans 38-40, 89 

Medicare Private Fee-for- Service Plan 9, 90 

Medicare Savings Programs 76 

Medicare SELECT 16, 20, 21, 25, 55, 60, 90 

Medicare Special Needs Plan 9, 91 

Medicare Supplement Insurance (see Medigap) 




95 



Section 12: List of Topics 



M (continued) 

Medigap 

Basic Benefits 

Plans A through J 18, 43 

Plans K and L 19, 44, 45 

Extra Benefits 

Plans B through J 20, 46, 47 

Plans K and L 21, 48 

Steps To Buying 42-52 

Under age 65 66-68 

What It Is 12, 13, 90 

What's Covered and What's Not Covered 16, 18 

When To Buy 26-28 

Why You Might Need It 14, 15 

Medigap Benefits Chart 

For Plans A through J 18, 20, 43, 46, 47 

For Plans K and L 19, 21, 44, 45, 48 

For Massachusetts 80 

For Minnesota 81 

For Wisconsin 82 

Medigap Policies and Medicare Prescription Drug Plans 38-40 

Medigap Protections 54-62 

Military Retiree Benefits 76 

N 

No-Age-Rated Policies 22, 23 

O 

Open Enrollment Period (Medigap) 26-29, 54, 66, 67, 90 

Original Medicare Plan 9, 10, 90 

Other Ways to Pay Health Care Costs 70-77 

P 

PACE (Programs of All-inclusive Care for the Elderly) .... 55, 56, 58-60 

76,90 

Pre-existing Condition 24, 26, 29, 31, 50, 54, 67, 74, 90 

Premium 10, 13, 22, 23, 32, 33, 90 

Prescription Drug Plans (Medicare) 4, 5, 38-40, 47, 62, 75, 89 

Preventive Services (Care) 4, 20, 47 

Pricing Policies 22, 23 



96 



R 

Reliability 36 

Retiree Coverage 72 

S 

Skilled Nursing Facility (Care) 15, 20, 21, 46, 48, 91 

Special Enrollment Period (Part B) 28 

Specified Disease Insurance 30, 77 

Standardized Medigap Plans 

Plans A through J 18, 20, 43, 46, 47 

Plans K and L 19, 21, 44, 45, 48 

For Massachusetts 80 

For Minnesota 81 

For Wisconsin 82 

State Children's Health Insurance Program 77 

State Health Insurance Assistance Program 6, 20, 21, 38, 49 

54, 66, 85, 86, 91 

State Insurance Department 20, 21, 35, 36, 49, 52, 54, 85, 91 

State Medical Assistance Office 76, 91 

Switching Medigap Policies 32 

T 

TRICARE 30,76 

U 

Union Coverage 30, 57, 72 

V 

Veterans' Benefits 77 

W 

Waiting Period 31, 67 

"Welcome to Medicare" Physical Exam 4 

www.medicare.gov 4, 6, 10, 49, 75-77 



Note: The information in this "Guide" was correct when it was 
printed. Changes may occur after printing. For the most up-to-date 
version, visit www.medicare.gov on the web. Select "Search Tools" at 
the top of the page. Or, call 1-800-MEDICARE (1-800-633-4227). 
A customer service representative can tell you if the information has 
been updated. TTY users should call 1-877-486-2048. 



97 



cr !S LIBRHRy 



U.S. DEPARTMENT OF 

HEALTH AND HUMAN SERVICES 

Centers for Medicare & Medicaid Services 

7500 Security Boulevard 
Baltimore, Maryland 21244-1850 

Official Business 

Penalty for Private Use, $300 

CMS Pub. No. 02110 
Revised April 2005 




3 flO^S 000110™ 






CENTERS for MEDICARE S MEDICAID SERVICES 



y- 



To get a free copy of the "2005 Choosing A Medigap 
Policy: A Guide to Health Insurance for People With 
Medicare" in Spanish, on Audiotape (English), in Braille, 
or in large print English, call 1-800-MEDICARE 
(1-800-633-4227). TTY users should call 1-877-486-2048. 

^Necesita usted una copia de esta guia en Espanol? 
Llame gratis al 1-800-MEDICARE (1-800-633-4227). 
Los usuarios de TTY deberan llamar al 1-877-486-2048.